9711-073 (BLCK)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 # Lic. Class Exp. Date
r 693899 f''j.. `� _$/3l fa8
Date 1142 - 1'7 Signature of Contractor /' 'r""` _ ��
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 Policy No.
S`1'AT8 FUND 046-97-000692.3
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions,✓`
Date: I r T4. X19 Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on ,his
application. r
1. Each person upon whose behalf this application is made & each person atci
whose request and for whose benefit work is performed under or pursuant to,
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any. permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) '' ' µ ! Date
14
PERMIT# CONTR/O�L#
BUILDING PERMIT
6 DATE VALUATION LOT y1(,�.�7 TRACT / Q 3
11/2:4!9'7 �9.�iI0.00 v F.. V ,
JOB SITE _TPN
ADDRESS
79-140JACKRABBIT Tit
OWNER CONTRACTOR/DESIGNER/ENGINEER
Mi'NX;yTREW CON$rr
50.445 MOUNTAIN SHAC3S)ArS
LA QUlNTA CA 922 53
USE OF PERMIT
1380 &n .fZ of 6 ft garden wWI
6 FT. WALL
MINIS7RELLI-PAliNTED COBE, INC.
.0445 MOUNTAIN SHADOWS RD
L_k QUrNTA CA. 92253
(760)5654.1849 CBL # 3625
"340.00 LF
CC.11%Wf ED CUSS OF CONST.M.14)010N 9,.`�!1lf.lili
PERMIT MIT F E SIJ'MAiEVRY
CONSTRUC CION FEE $117.00
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Pk-IJ)"OTAL CONSTR1.:fMON Fin PLAN CHECK $11701 LESS PRL -PAID FE XS 50.001
Npv 2 51997 TOTi% PERAT.1T F E:rs DIS; NOW 5117.00
RECEIPT DATE BN DATE FINALED INSPECTOR
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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 Plbg. Test
Final I
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:
f
1/30/98 ; CITY OF LA QUINTA
INSPECTION SUMMARY REPORT
Permit Number '9711-073
Site Address 79-140 JACKRABBIT TR
Rereference Number '
Site City
Location of Project
Date Applied for 11/25/97
Date Approved
Owner Name MINISTRELLI CONST
Date Issued 11/25/97
50-445 MOUNTAIN SHADOWS
Date Finaled i12/ 4/97
LA QUINTA CA 92253
Date Expired'
r '
Contractor Name MINISTRELLI-PAINTED COVE, INC.
Valuation $9,500
50445 MOUNTAIN SHADOWS RD
Fees , 117.00
LA QUINTA CA 92253
Description of Permit -380 lin ft of 6 ft garden wall
°INSPECTIONS SCHEDULED OR COMPLETED
Scheduled Completed
Date Date Time
Inspection Type Inspection Result Inspectors Comments
12/1/97 12,' 1!97
Al -FTG PASS
12/4/97 12,4!97
B6 -BB PASS
12/4/97 12; 4.97
D2 -COMP** PASS
3 Inspections completed.
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