9711-014 (RPL)'l LICENSED CONTRACTOR DECLARATION
_I hereby affirm under penalty of perjury that I am licensed under provisions of
:Chaptei 9'(corbiriencing-with Section 7000) of Division 3 of the Business and
Kofessslonals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
X31193
7 1 r7 t
y ate ! 1 � Signature of Contractor,Z &) Z
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
contractors to construct the project (Sec. 7044, Business & Professionals
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.
( ) 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:
Carrier'i XC-N1fY1'.!0.N OAN b I€1 Policy No.
,..
(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
ubject to the workers' compensation provisions of Section 3700 of the Laboi
Code, I shall forthwith comply with those provisions:; -.
Date:111011-11 Applicant t5 <IC ' fl't.d c�L: «r ,
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 cancellateen.
I certify that I have read this application and state that the above information is
coipFect. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to .enter'upon
�e above-mentioned property for inspection purposes. }
Signature (Owner/Agent'Z ��/w""� Date a_ j �A
PERMIT" I°°NTR°`"
BUILDING PERMIT 4a7dR�il��d.
/.
DATE 41) 6/97 . VALUATION f;161i& 0,1N1 LOT TRACT a� .
$305 3 oV
JOB SITE - 51-240 ka�'EN�IDA VALL�,JO
APN 77.�.4�i1?3-�.l( �.
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
JACK ;yAR4. JR.
L✓7
54-3330 M-TENIOAHOW.611A,
5-4_35t;AVENI_DAri:i^iiitEkak
LAQUINT'A CA 92233
L.A.CA 9243
{rtitP15Ci1t-351 i f;331.;; 11.15
USE OF PERMIT
gCKA
y�
POOL A1,!i3/0R'P& 10, AK) LS
'
- DS!'�.iil�1 � !, !� i�+�v a��,fll:0.1�'RJ•NA's A,
.
PT.ANC.'4#'1:Cfo' Pli—El 101-!I[H}-439-318 76.05
tol-�1atC11A,ai!8,*) ,60
$117
I�r't��:3�t;�i'1`9�att0n'!'.lt:�?y'd'.►..iTE,
20-000. r,45.00
py a�
81.,► Z. CY{`.11, CON ni U(:.'1`!t. N, Nn pt 4ApN C3411 .t
,X /$�_�?y��
'LESS 1�,/.�.^'6
p ^ y Y
NOT 0 6 1997
OEGEIPT �" `
DATE V
BY ?
DATE FIN
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
ti. BUILDING APPROVALS
MECHANICAL APPROVALS
Set Hacks
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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:
a�
a
�I
Rl
- Or LA QUINTA
BUILDING & SAFETY DEPARTMENT � o
zo
CONDI`PIONALLY L _
PT D FOR C®NSTRUCTION - -
SUI ECT TO INSTALLATION AS PER -
- v7 -
'
AND ALL APPLICABLE CODES
CONTRACTOR -�Q ���- '� dY�� - ADDRESS. --
OWNER JOB ADDRESS-
This form shall be eosted on the job with the Building Inseection Card at all times in a conspicuous Place.
It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that
are on this list are the same persons performing the work. Any changes to this list must be approved the
City of La Quinta Department of Building & Safety adm to work being performed by a changed sub-
contractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit.
E
SUB -CONTRACTOR'S
NAME.
TYPE OF
LICENSE
STATE'
CONTRACTOR'S:'
LICENSE
NUMBER
WORKER'S
COMPS NAME/
NUMBER ON: DILE
CITY
BUSINESS
LICENSE
NUMBER/
EXP. DATE
i
r��=5 E XCA%14T 4
At 1�
I 2-3913 -`� 7
FFXCA"ATEY`
C-34
/C-8
ONS
ASPHALT
A
B
FRAMING
STEEL/
STRUCTURAL
F
C-51
3 2G�
/�3/ '1�
,!/�� �J�
S/�/y8
12 3, A 7
MASONRY
C-29
PLUMBING
LATHING
C-36
C-26
J�si�
i3
3 1 11T. ►z 3-
DRYWALL
C-9
PLASTERING
/ # F
C-36
lee
HVAC
C-20
ELECTRICAL -Q�
(General) DY`
��QE�- ��� S
C-10
ROOFING
C-39
SHEET METAL
C-43
FLOORING
C-15
GLASS/
GLAZING
C-17
INSULATION
C-2
SEWAGE DISP.
C-42
PAINTING/
D
C-33
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