9606-159 (RPL)U)
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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
c530401 B 10/31.7
ate' " Z" Signature of Contractof.
OWNER -BUILDER DE,CIJARATION �+
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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:
rl have and will maintain a certificate of consent to self -insure for workers'
c Vensation, 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 isFissbed!?' AV-'Wo'rkers' compensation insurance carrier & policy no. are:
Carver 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' ompensation laws of California, and agree that if I should become
subje5ero the workers' compensation provisions of Section* 3700 o the Labor
Co I shall forthwith comply with :those provisions. �' , "
t`e: s 577 APPlicant � ,Xk A V-7
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
e.
whosrequest and for whose benefit work is performed under or prsuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quints, 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..l. 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 pt7rposes.
Signature (Owndna Date
BUILDING PERMIT
DATE 6127/96, VALUATION $9.51.21011111 LOT
JOB SITE 79-195L.r1� IGO
ADDRESS
OWNER
}f.S3�l,�t.f� �.' cfC lrA�lf,:�`1' €1;.1,1•.15,
79051.11T.1 W,wtti�
LA QLINI-A: ('A 922,5,3
USE OF PERMIT
PhTi0
PERMIT # CONTROL #
9606-159 3624
TRACT
APN 6/j4-Z63_01S
CONTRACTOR/DESIGNER/ENGINEER
J,Fi -1f.SS DALTUN GENERAL C.°W111AC
30255 AM SEL YURA10
CA'!'I EDRAJ C°WY CA. 97,31
k619)770_0260 C"f3Ltt 533
CS'1'V"TCD CUST OF f e3NS'aX=iON
PERMIT VVY N081MARY
iPLA.N C,KCCK FIM i.f)1-f3EJf)-q i4'a3:i K $70 1116
C'CINST .UC1101N.r.EL '.fom#G"1.8,000 $1:03.00
:31 t 3N� + a1�iFJ i 1 7<i .lr# . Ftn SLf
1101-000441-000 $.a5
SMtCY AL r'ON.SfRUCf:IGN f1ND PIL..AN CHECK
LE SS 1>RE PA10 PR'3,
,Y.�t,�i.}?bf L�r7L l�����,�•.i� Jt�.l .���I �J �IF��Y�
DATE f I By/ a _ I DATE FINALED I INSPECTOR
8,5,2.00
$11799 05
$0.30
$179.0.5
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade 4
Return Air '
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap OF
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
Y
Drywall - Int. Lath
Final
Final
POOLS - SPAS •
BLOCKWALL A P OVALS
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
Neater 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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)