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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 E p! a e
518742 C/�J.l � � �k'3 194
tiDate Signature of Contlr`actor
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).
( ) 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.
(.y) 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.
ATE Ft WD W341=-99
(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+far w}�1C this permit is issued,
I shall not employ any person in -an y.manner so; asllto, become subject to the
workers? compensation laws of California, an agrge that if I should become
subj e't to the workers' compensation ,previsions! flSect' • n 3700 of the Labor
C9de, I sh fo with comply with-th' pl rovi�ionsii
'bate: Applicant—
Warning:
Warning: Failure to secure Worke s' Compensation overage is unlawful and
shall subject an employer to criminal penalties and civi f nes 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,.,) agree to comply with all City, and NStaterlaws.relating to the building
construction, and hereby authorize representativgs�of)rthi ity to enter upon
the,above-mentioned property for inspectidn purfpos s:
,Signature (Owner/Age6t) `�` , Date
BUILDING PERMIT PERMIT#
DATE VALUATION 319AWse LOT TRACT
41
JOB SITE 45 APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / ENGINEER
ERIC & KIM CRYS'TAi. AMEfdCAN' WXA. CONSFRIT'ni( N
45-095 DESERT FOA 73900 HIGHWAY I I I
LA QUIN rA CA 42253 PALM DESERT CA 92255-W&
47601340-258'8 C BL# i RA
USE OF PERMIT
P(.x,) . APii) (JR SIVA
IkAA. & SPA ONLY - ALARM&BAIWEkS WALL BE IN, PLkcE Pa
I4tFeP1.AStI%H INl317K71QN
it A)L ANWC& SPA
19,000.00 LS
fid INIA• ED CIC1':TT OF C NSTRUC-TION
eF.RM IT FEE SUMMARY
PLAN 1LIdwX F[+.
101-4R1t)-4-W-.318
3128.79
CY INSTR Y R—rI U N F'F
10141(1()-A I X4lil()
S I9R. tUO
%WCILV4U7AL FIX - f*)01.
101-000-421- ff
$24.00
1.10.3'KICAL FIiE -- P(.*A.
101-C)4)Q-420"
S45.W
PL.UMBINO bU -- Pt K JL
1014M-419-Efl)1Y
$27.00
M, I R -TOT AI—C OWS"11t11(-' TC,)N _ANt) PIAN t'HFCK
LESS PRE -NUN FETES
TOTAL 111KRMIT 1' :9 DUB: N4J1W
RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
.l
v
"7'2 70
$0.00
$122.78
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
Insulation
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 APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
17
6—
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Q®/
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
�—jf�f' y
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)