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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 # I Lic. Class / Exp. Date
Date �, Signature of Contractor -
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 lksN.i`l.`lY .1.N'i- C 1. Policy No. 20420"901 -le
(This section need not be completed if the permit valuation is for $100.00 or less):
()Ice fy that in the performance of the work for.which this permit is•issued,
I shall t employ any person in any manner so as to become subject to the
workyfs' compensation laws of California, and agree that if I should become
subject to the workers"compensation provisions of Section 3700 of.the Labor, -
Cgde, Lshall forthwith comply with -those. provisions.
ate:' %// . Applicant" -
Warning: F ilure to secure Workers' Compensation cove"rage Is unlawful and
shall subject an'employer to criminal penalties and civil,fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at t,
whose request and for whose benefit work is performed under or pursuant to '
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
corrget. I agree to comply with all City, and State laws relating to the building
cc dtruction, and hereby authorize representatives of this City to enter upon
th above-mentioned property for inspection purposes.
ignature (Owner/Agent) -- -�'�� `r T Date
1EBUILDING PERMIT PERMIT# CONTROL#
964"74 3517
DATE, 19 9� VALUATION LOTTRACT,
JOB SITE APN
ADDRESS 4S.4 3.5 �?[�;,4�+;RT Alit DRIVE,ti wrt(3�1-3$�-t1(b�
OWNER I CONTRACTOR / DESIGNER / ENGINEER
r• ;xrr 17)' � 5 tfF! •f'ti �, t
1335 Sts. "LO SCi:�.i 1 1111N. 1r200
SAN HIRK dAltMINt CA, 924
USE OF PERMIT
1140NNUS .ROtW AT)Dn'10NV - PLAN 5
NW.73,RE FQK Al DIT10NAL it ME`Jd
N111`t' CRO
.!'E!-:1, C'EJR1 t;J1+1:T'iliti
..,.
133-S St's. "0" STXf ET, S-,'1'1,' --200
SAN HERNA.i.(:i)INO CA, 92408
009MI-6007 031.0 1.120
M.00 51,
COST t;11F CONSTRUCTION
pp �• 3i s�py�yy•�p.•pd p .i:)r�Vy3'IRi[A'I"ED
PLAN CKCK FEY
101.0110-134»3t8
576sUs
C 014S'[i4.UC' ION, fu.
101.000418-:)tH) ;
11 J.Oti
:.- i�7�%.'1i'AL�fI'tU-, ht�;i
ltit-GO(1-dZl,iiu(1
x➢,9i10
ELECTRICAL f~'.EE
101-00.420-000
S 4004
`rLI)MB 1•_N0 J."•'E�Ei
1(?t-01 t► -dict (1t 0
SiS3.0 ►
STC)cN* MOTION ION I`ll, -1t.E,ST1}
101-000-2M 1-000
$1 fJU
tNFRASTk1.1C;.1't IRF FEW,
22:5-000wW-342
$Z0.8, 1
Il9tS�:11 LAtV (3US
101-000-423-000
5;koko
!N F "1iUA1'1f�t+t1 a.i
101;�O(Ni lzi-1.x,)11.
$460.(*
9,99.3.54)
OU13•' 10TAi, C".r 1tvS;I7:.t3C:-'T ON AND PLAIN �;HEr"'K $652.08
PA'
LESS PRE-PAIDPEES $1,00
DEC 19 1996 ToTm., PERMIT FEES PiUE NO3W $652.08 ,
CITY OF LA QUINTA • A
RECEIPT DATE BYE DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs O&nderground Ducts
j
Forms & Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
OX to Wrap F.A.U.
Framing Compressor
Insulation Vents
r
Fireplace P.L. Grills
AI
Fireplace T.O. Fans & Controls
Party Wali Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
01
�Final
Final POOLS - SPAS
BLOCKWALL P ROVALS 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 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
COMMENTS:
Final
Utility Notice (Gas) -
ELECTRICAL APPROVALS
Temp. Power Pole l
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)