9605-122 (SFD)LICENSED CONTRACTOR DECLARATION
--I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of'the Business and
Professionals Code, and my License is in full force and effect.
License .#, ic..,Class Exp. 0 to _
;39{33/'):► .. 11131197
Date � Signature of Cont;;;;a¢tor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the:Contractor':s
License Law for the following reason: r-
( )• 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:
O 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,
(. ).,A -have and,will maintain .workers' compensation ,insurance, as required by
Seec'tion 3700 of ;NF( abor Code, for the performance of the4 rk forgvhich this
/permit is Issued My workers' compensation insurance ea'r`ner & policy no. are:.
Carrier Policy No.
(This section need not be completed if the.perrnit 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 provision -g' of,Sec bn 3700 of the Labor
Code, I shall forthwith comply with those ,,revisions: • •
Date - t"' - Applican --
Warning: Failure to secure Workeeff-CCC pensatio"` n c�e 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.
1 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 authorize re'pree�sse�ntatives of this City to enter upon
the above-mentioned property for'inspection purposes:.
tt
-.... _.
Signature (Owner/Agent) Date
# °°NTR°`#
BUILDING PERMIT PERMIT9605-122
DATE 9/ 5196 ' ' VALUATION .$2.44.340.60 LOT ' � TAACTO34 3:950
JOB SITE '57-795 SOUTH VALLEY LAN le,
APN ` 7610M)k,3
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
J01 -1N .f GO A:;sIl:.k.
MM CO.
41^910130,, KDWA1LV A.40'
41-910 80Atil)'WAI KA -10
PALS I DE -SE -KY CA. 922111.
PALA1 DESERT CA 92260
6197764840 •
61.97764840 C OL4 21329
USE OF PERMIT
i� tvi i,:f3 #{.w t�iii•;1� 1� 1'1:31 tF
SF0-.P.H1WI'r oms 1 -o r 1NfZF.C,OE 131.,rX.K. WALL OR: POOL.
1'ta1iC'N(PA 1'.I't3 '7R0.f* 41+
GARAOWCARP(;J12`_1' 7, 1.6o tir
COST OF CONST RtlCJl IaN
:244,940.60
Ygg ppnD♦yAAaa Ss 4 5; s9 q r(t)�ti/'1'.Ilt!3M1.1,D
iy4J.ittlA i,! .�7=i i'e �4,1 �'11��14�0i. L
iNS'17i,1.lC"i°kC►Pf'Fr 101•0(N1AIK-000
PLAN C131st K 10.1-13(30-439-318 $963.72
idflit'~PI-K ICAL 1766 10/1140)-X1'4.1-1100 $11•+ 330
HLR'(_7rRICA1w .FFY. (01.01XII-42.13-!)(.!0 T255.7a
:�'1„t!744�f'1St� ��:C�: • 101 L�}..�l1�y()!�? �la�.2S
ST014e, iY.11.0t4 FU4i21 r,) i.l1 $274.49
�ii<.ILOlt�lt r ! F'H • ! fi i tu3t1'�4� �Ot30 - S2f! �N)
... [PdGt:.t:A's l'1�t i�;`r1dC21:;1"I".ks t� �iJUU>�143-342 �S,23A.4f3.
�t"f` 1'n' F'Ia.Rj^'.fr,� �'1r��C'73,5 - tZEt311: 70l-1.3?)i3-ZSe�Ottt) Ss151.1U
$03-tUTAL`4..ONS-CONSAND P1 ANI CH121 CK
3,101 • �
1,ss vlt.ir-�P.Mo P1.Fls-
-$500,00
SEP 0 5-19.961.
RECEIP,T'.
DATE
By
DATE FINALED INSP T
�..
G
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE 7F7INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings - (yt
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines -2.
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
ewe Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power PoleCl-
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)