9811-070 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
car W Professionals Code, and my License is:in full force and effect.
0 :5 M License # Lic. Class Exp. Date
W
^ 714158 Ci 1 ifif3l;�
rZ
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c Z 1Y(Signature of Contrpo, to
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J U OWNER -BUILDER DECLARATIQ
H War I hereby affirm under penalty of perjury that'I am exempt from the Contractor's
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).
( ) I am exempt under Section , B&P.C. for this reason
U)
C\I 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 ) 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:
Cartier Policy No.
(This section need noYbe 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' compensati u�sions of tion 3700 of the Labor
Code, I shall forthwith comply h th se. provision
Date 4`GOApplica "
TQ i
Warning: Failure to secure Workers' Compenti n coverage is unlawful and
shall subject an employerto 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_".*Specjibn purposes.
Signature
Date
BUILDING PERMIT PERMIT
9421.0740 1,
DATE VALUATION $91.6".60 LOT 40 TRACTJOB
§'ItE
ADDRESS 4?-ii0 bf,115111- , �1lIRIVF
APN 6014-372-10004
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CIEI' (MIRY C;ROLi;`ELL COIIlMU;~ MES
C- N','UI:Y C.ROWFILL Cc.1n11(f11HITfL'S
1335 SO. "D" STKERT, ;M. #2.00
153.5 SO. "D" S T'h.Lfh.. I', SPE, 3200
SAN BERNARD[KC) CA 92408
SAN BERNARDINO CA 92409
USE OF PERMIT
r11V(iU #ANl11 1-DW'Ei.j.. NG
LOT ;W - PLAN IC SFD T f'.OLNU'T DOES NOT [W.-ILDE, 13LO►cK WALls
OR K)OL,
'Inas e CCiNS17 UC."i'MN 1, i Ni.(i(3 Si
GAR AGOC:Ut► cju , 661.0O SF
) 'STIMAT' ID C€ SY On MNSYR-1.11.7ICYN
91 ,dvSf).;1:
P E;ijrMIT d< #' E SUNdNiiARY
CONSTRUCTION 101-At►0-418-OW .1603.5o
K.A K r`�tr C'K Pc; F 101.nlltt-[1 t .:8 19
! f E. rruCALFEE 1111-(►t)t)-420_ S1!°2.4:
!'LUMBINO PFTs 101-00)-4j9-000
til f.'ilN(7 lbff'� rt(�N >N F.[:. _ R Vtilt? 101-I1(tf1-�4 f 401 Ty t
Gf2.:LDING F1' 1C1.000 -123 -OM1 $20,00
[Nl;Kr1ST RUCTUKII, FEE 2215-000-443-342
S! JR -'1i MAI, AND PI,A-N (7-fRCK
$3_.4117.49
I RISS PRE -PAID 11X
".01)
DEC 15 1998 '11.0- -Al', PFIRM111- F EEi 0133 NOW
r '
RECEIPT
DATE
BY (
DA ALE
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
InsulationEli
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 APPROVA S
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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
Poot.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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) xw f'77-