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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
714lot►
Date /g7-/, ignature of Contract
OWNER -BUILDER DECLARATI N
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.
GOLDF'N' INS. TIM,' `P110161 -ft l
(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 wi"M isions.
Dater Applicant ..-.
Warning:. Failure to secure Workers' Compens6tthn 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 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' pection purposes.
Signature (Owner/Agentl�E ex Dater
BUILDING PERMIT PERMITQ#
DATE VALUATION LOT a TRACTJOB
SITE
ADDRESS 4i7l-_ 20 T1,9BB�P+�Il.{h. DRIVE
APN {{14�.�/Z-YJQOfl
OWNER
CONTRACTOR / DESIGNER / ENGINEER
f'+Tl'tiI'f n>Y'f'�t`rstinrf:f i (+nP.Aa AT IRi1T1};•�
. ..�. is .it .y. �.r .1..4w ...,.+w...l�—•l�t.l ..r
1117t..F'�'1'li»r, !''1�I t\#r1711 f'�!'I�AiL -tl�l�l1'iYl: l"y
�. i.t.
1535 SO; ? `5iVRIF;'i', a "r'„ 62W
i533 So_ "U" ECRFF7, S,1T. ;1200
Silf�i FtEsitt�►/�FLJIi~)f:J c"A 91.4108
SAN €3ERNAitUtN0 1_'A 924'09
'400 liti 1-t;()fl7
USE OF PERMIT
SI V0L8 f-AIMAN OWEGL.1NO
L0 -o _ IkAN i(AR-3, si J,) - HFP M1•:t' INCLUDE E i.1i. OCK
WAL1,`i tik 1'('X)L. PLAN C#.U3eX FEE tUJ)l1',GF) ?Yliq VOR toUL i'lPLE
t S[tA}4C2 OF SAIF Krl.ld l Y•PE,
TItAC TON I,803.00 3F
GARjVjU+`Mk1)0R'i ii12.f1U SF
iw TTINMlil'.D (70. r OF
PRAMIT FEE Sf NGWA V
05N -1'Y UCTfoNFFY-, lfl1-(lift)-4lK-iIUU $(iiS•t►i1
Pt ,AN (714FC`K iVEY' 9 $1409 74
i4.1EGIAi'al(.:AL FEE 101-000.421-000 S535t)
r'LEt:'rRICAL 1 i;S . 101-000-420-000 511211.4-5
PLUMB INO FUN I !l l -Coil-41'x-i)tlfi � i :id. "Is
STT-ONG {V{0T!4r).N f'"' - 110.14"-2414 $i !.03
0RAD1%TG F1311 1.01-000-1123.000 V40.00
INFit.A'i'IitU'G':i'L?'ltli'ff3i3 .22,E i0-443- 42 $2,=18594
ART IN VIJli.LIC PLACE -S - RIESIC 701-000-155-000 ti2G:3a!
iN ANO PIAN ("'F1((',K
ES
DEC 15 1998 TCD`6'l9LPE,18MIT rr EFS DQ]F NOW
&1,67.e.6.5
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
S
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0,.K. to Wrap
F.A.U.
Framing
p
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
a ?
Final
Final
BLOCKWALL AP"VL
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 .
/Z& 4z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
'IFPool
Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Q°
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.L.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice, (Perm)
COMMENTS: