9612-068 (AR)LICENSED CONTRACTOR DECLARATION
Cf) I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of th Business and
r W Professionals" Codef, and my License is in full force and effect.
O Z) M License # t Lic. Class k,— Exp. Date y
O r <) f+1147 r 'B V3 !!97
t R 0
ZO Date Signature of Contractor f /
CO~ OWNER -BUILDER DECLARATION
_J 0LU LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
c`') () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0
Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
U-)
F2 O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W tL compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued.
QU ). I have and will maintain workers' compensation insurance, as required by
O C) Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
,;t z Carrier Policy No.
Cb O > KrH PTIN1D t 371py5'�1
J
(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 isissued,
I shall not employ any person in any manner so as to bfecome subjedt to the
workers' comperisation laws of California{ and agree that if IJ#shoutV become
subject to the workers' compensation provisions of Sectif n 3700 of the Labor
Code, I,shalll forthwith comply with those provisions. /
Date: ) t' b Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is uplawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and sta� that the above information is
• correct. I agree to comply with all City, ,and Std to laws re6ting to the building
construction, and hereby authorize represent tivef of this City to ente upon
the above-mentioned propertyi,, nspection p rposes.
'Signature (Owner/Agent) y X Y Date
PERM T# °°NTRD
BUILDING PERMIT
���-�� 4469
DATE 17jiQ/g6 VALUATION S1;.219ilk LOT 71 TRACT 1ZL
JOB SITE
ADDRESS i�j^S47'i'IA C.lRn.t�E
ADDRESS
y�.�
APN 64�21[01ri�4
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TD MSERT T) W1,C11WEiNT
SPARKS CONSTRCK"I ON
Vt.), Boo 1716
702y5 kANC110 LSA QU1NTA DR.
1.AOtUNTA CA 142253
LAQ01N'1'A. (.'A 142253
f.619)7714041 CUR 2W. 6
USE OF PERMIT
Rit'810PNTIA1, A1Jt)1TIO N
A01) 180 3Y, f0 O ti &i 1trX)M tilll,62 OU V°ALUAT10N) AND 170
S K r.)1: VC)'4ERW) IkWCH WV4,Y! 04) VALUK110NI
RiNk-%X1- C"1.)'.,1'+ +iN 13,62$.140 5 .
tif2RC U['rS:1'iC? 270M0 3E
1'.N:.1rtMI T NU SiiMMARV
PLAN4`1tiA_'1C Rif' 101-00"-V-3111 3111.15
00WIT01 R'ViON f7r, 101-t?W.-419-000 5171.110
tali C"HAN1CAi. FUT 101-Fi(?0--121-W S13.00
t41.1>C`fRWAI,.FI% E, 101-M-4204)OO $21.30
IN i2AS17L11tTlJitfJFEE 225-M-443-342 $261.611
S'rE)N{)1ViC3`rION FET -10.30) 101 -OW -241.011X4 31 5y
A
S1A.0T'
��l.�i
CITY OF LA QUINTA LESS PRE -PAW FEES
$0.00
TOTAL PERMIT VMS 01 TE NOW
S'•ilxl.�l
DEC 19 1996
DEPT.
�EC P
DATE
BY
DATE FINALED
INSPECTOR
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 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 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
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: