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9612-100 (BLDG)
LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licens%d,bade .Vrovisions of Chapter 9 (commencing with Section 7000) of Division 3`6f the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class V Exp. Date 1&te f7Y 77 ¢ I; Signature of -Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) I, as owner of the property, or my employees with wages as their. sole compensation, will do the work, and the structure is not intended or -offered for sale (Sec. 7044, Business & Professionals Code). ( ) I, as owner of the. property, am exclusively contracting with licensed r contractors to construct the project (Sec. 7044, Business & Profes'sionals Code). () I am exempt under Section B&P.C". for this reason . Date Signature of Owner WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty, of perjury one of the following, declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for.the' performance of the work for which this permit is issued. f '(±Q I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which.this permit is issued. My workers' compensation insurance carrier & policy no. are: Cartier,f�� Policy No. TATE FUND 1371W9996 (This section need not be completed if the permit valuation is for $100.00 or less). () I certify that in the performance of the work for which this permit is issued, I shall not employ any person in,any manner so as to become subject to the workers' compensation laws of California, and,agree that if I should become subject to the workers'. compensation -"� I p .•pfro4islonsof°Section 3700 of the Labor Code, I,shal(forthwith comply with those=provisions: Date: ,(` r e''+�' Applicant Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth 'on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall: indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of'such permit, or cessation of work for 180 days will subject permit to -cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City,.and State laws relating to the building construction, and hereby authoriierepresentatives of this City to enter upon the above-mentioned property for inspection purposes,.— Signature (Owner/Agent) Date PERMIT # CONTROL# BUILDING PERMIT 9612->00 4505 DATE rOl�S► VALUATION ey M�#��i� LOT TRACT ADDRESS 74)-.�i}S . E•oN.�+.',(,;,vrc, JOB SITE APN OWNER CONT��R��ACTOyyR/DESIGKX NER / ENGINEER (+fEE tO7, 7, Vii}+ . AA." TE, 93RANCHO NC.d- O .LA 4 Lrt1+dTA Det. LA UI)KC.A (;;A 922.53 LA QUiN'1 A CA 922 3 (6t9)77149 l C111,11 M6 I USE OF PERMIT 0r:NEkAll.. B(ALi":il(NO 1.0 L. . i' (lAitDEZIN WALL. Ut x" S'I':+ 40AIW h FT. WALL 100.00 LF SUMMARY (":C;i�ST'RlfC�1�It.)tti ��.� �a!-t}OU-�a.s�►�a s�4.+so PAID B -icy M, COW,7t,OC (ON AND PLAIN C IRE-_ K 'uk's PRE.:r>AUD FEES DEC 17 1996 TOTAL PE 'off FENS gild+l NOW CITY OF LAQUINTA I RECEIPT I DATE DATE FINALED I INSPECTOR 2,500.x0 1 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wail Firewall Exterior Lath Drywall - Int. Lath 1 Final Final BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: . . . I . I I .� I . . - .. . . . . . I . . � - - , � . - OF LA - QUINTA, *-.'. ",- " � - : , I . -1 . I t 1) ,CITY I - . .1- '. . . �.- i.'.- I � 41'.-� ��. . "' -- . I .. �� . . . , - I . 1. . ", "I � - 1% .. :. ".. . I . il . . � � - "'' , i I."...- I,.' -1. . . . '... � I . I . . . I - I .. .,,,' - .: . . . . - . -- �1 .." . -:... . .. ".. .SUB -LIST I --.. .1 1. -.�, 1. . ''-- ..,...-.,.;. .1 I .. I . . - �-� .-.,� -.--.-�--,-"� �, , - A, �_ . I.. . �- .. . '' , - .. 1. I � .1 , . , � �_.-�- ..."., 7'. - - - 1. . � � '. � � . . -, � -. �t , I � � - - - . - � . . �.. . -1 � .t., ., - ..,. ��... i , , .1: . .1 . I :� ., I � I .. -.� - " - �' 11 .. ....I - 11 ".. . to. .I - '-., * . - . .... . I*; . - 1:1 , I... - .. ..- I _ . - A,�.-. - I . � . � - I . I ...i , - * .. 0 . . I.- - , ,,,, , .. � . . - - - I - 1-1 - , 1-'11 - .1'.1 ". ..� .. .1. - . CONTRACTOR --- P-& "C;�S-rR�uql&Al *1 I I j - ADDRESS 7q -30.E :'tS-F - -..'. - .-. 1. .. . - . .IF (7 � ,-�-, . I ."� - , . - . � - P , . . . . . . ,7 . 14 i . I -- ' - - , ,� . - I .;� " - : . .. I I . . . . . . , - � �-- : : " " , ,OWNER -.:. 14A- -:5 - . . .. . JOB ADDRESS--- . . , I t. - "'. � , ,,,, , I � . . I . � . . - I . . . . - � form . . .. I . "I - - . This form shall be posted on the job with the Building Inspection Card at all times in a' 'conspicuous - p�lace-.,-,:�. . ., ' . - � I I - . - �- .1t is the. responsibility of the General. . C . ontractor of the'Owner/B tuilder'to . I monitor ; the' I sub-cioin�traciors that - I '.. . I-- . I . I I- � . I are; this list are same persons performing.thb work.. Any changes, to this'list.must be approved. I . . . . . . " changed - � . City of L6 Quintia' Department of Building & Sa , fety ��tto work being performed by., . � � ch I angpd - su � b-;, `�, . . I . . � . - I .- ., - . . . . . . . . . - - I - I " . . - � � . contractor. Failure to comply will result a -stoppage of work and/or the voidance of building permit. - � . - o .1 I � ; .1. I � � '. .. . . . I I 1. . . , . - . . , I - . � . . . . I ....... --:- , - ......... "'x: ..... -'i�li�-: ............. .. � - .. ....... . .. I .............. . ........ 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