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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (comTendifi6 �vith Section MOO) of Division 3 of the Business and
Professionals Code–,a(rldm� License is in full force and effect.
License # Lic. Class Exp. D
W.. !68 C55 13
VDate' 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:
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).
( ) 1, 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 . —Si gnature of Owner
WORKER'S COMPENSATION DECLARATION
I Oereby affirm under penalty of perjury one of the following declarations:
( ) I have and wil I maintain a certificate of consent to self-insLire 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.
(This section need not be completed if the permit,valuation is for $160.00 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 provision6 of Section 3700 of theLabor
Ode, I shall forthwith comply with those provisions.,
'y Applicant—
Date:
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 Safet'
y
for a permit subject to the conditions and resirictions set forth on his
application.
1. Each person upon whose behalf this application is made & each personat
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 forin-spection purposes.
VSignature (Owner/Agent) Date -
4,
PERMIT # CONTROL#
BUILDING PERMIT
9701 -065 4605
DATE -1/16/97 VALUATION $10,60.00 LOT. TRACT
JOB SITE
ADDRESS. 79-305IMSERTCREST DRIVE
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
DON JOHNSTOIN'
w r,,,;r rc, ,t NPOOL 8
4-4375 MADISON sr
LA QUIMA. CA 9225-3
IN 010 CA 92202
OM347-5959 1151
USE OF PERMIT
KtOL ONCY, 140 SPA, 140 fti�,A.T.Gk,
POOL A7.4OX"R SPA 111131
RUMON
1?1,AX CHECKFEE. 101a000.4,0-318
C�O'N STIRL(CM GN 1"'U, 101 -M-41,8-000- $124.00
I-I.ECTIUCAL RX —POOL 101�00-42,0000
KUNMING
�Q4-1'MAf, CONSIRUGROWAND PIAN CHECK
$279.90
P"A [D' 'SS PRE-PMDRES
"Wrm'. PERAUT 114FIR"i MWINOW
-JAN 21 1997
CITY OF LA'QUINTA
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
'OPERATION
DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
$lab Grade
Return Air
-ste-A
Combustion Air
fD k
Exhaust Fans
to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Firepla T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Patty Wall Firewall
Exterior Lath
Drywall - Int. Lath
I
Final
Final
. POOLS -SPAS
I I
BLOCKWALL APPROVALS
Steel 4 r. 4*zo
Set Backs
Electric Bond 7
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg, Test 77,
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 ULj!V'7 7 P,
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)