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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
I I I tts NW3 I i07
Date of Contractor
OWNER -BUIL R DECLARATION
1-1 ..-
I hereby affirm under penalty of perjury that I'am exempt from the Contractor's
License Law for the following reason: /I,-
( ) 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 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 71WITH 1143, CU. Policy No. 2W204001
(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 subjectI61the
.workers' compensation laws of California, and.a6ree that if l,sho6ld become
Su6ject to the workers' compensation provisi6ns ofSecti6n,3700 of the Labor
,6ode, I shaIL-fort*ith comply with thosig'provigionS.,-,�,'_;
Date: pplicant
Warning: Failure to secure Workers - ' ..CoKpensation coveraoe is,unliiwful and
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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
congfruction, and hereby authorize representatives'of this City to enter upon
t e above-mentioned property for inspection purposes. -A,
Signature (Owner/Ageht) Date
PERMIT# CONTROL#
BUILDING PERMIT ' 4541
-
T
DATE VALUATION -LOT RACT
8 23
JOB SITE
ADDRESS
APN
PWNER
CONTRACTOR DESIGNER I ENGINEER
(11WRII-11 V (111011111.1111.
c1DMIRV I'll, CION11 NIUNU11 [IS
153 SSO, ID ", S_IW11111, 4200
15 3 3 q,). "D " S7R EF V, E; 11-. h.1 W
S
SAN I�L!RNARI)1140 CA 1)2408'
SAN 11HRNARDNO CA 92408
CTIt.0 21 M
BIWAXIIN AGI * 'ILAR A.*),V_iC!AT1:S
USE OF PERMIT
SFD
'059 PASSLkQ AVE.
I OVAL tq! Uli,. QUINT A NOkI fi.
lfl,A,N SXIA1
6 3.QQ SI;
(JAK,A0fUC*AR1P0kT .576.iH) Sl-'
EYFIMATED OF CONSTRUCITONt
146.62S.60
foCkm IT FFIF, SUM MARV
PLAN CHECK FEF 10 1-000-439-118 S673. W
0ONSTRU(MON FrY,
MECIIANICAL F U—S
HLW_�TRICAI, ITIT.8 .101. -000420 -OW
PIAMBINO ITHS 1011 -000 -410 -WO 47 5
'TrR.owl MO- TfoN (RI71 1014"-241-01N S14,66
t01-000-42-1-000 126.00
2254W)0 -443-'V42 $3,280.29
ARTIN PUBLIC PLAMS (ki, S"i 701-W-255-000
OA Q.),T*'A,I,
CON,',`T*KM-0N ANI) P1,AN1 0 IECK
LE*S'S PRE-PAII)FEES
DEC 3 0 1996
TOTAI, PERNITFFTS DUE NOW
$5,301.59
CITY OF LA QUINTA
RECEIPT
DATE
B y
E FINALED
SP ECTOR
pi, f 4 t R ri L 1, : 1: 14 001
OPERATION
DATE
T
INSPECTOR
OPERATION
DATETINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel _L11,
Combustion Air
Roof Deck
Exhaust Fans
OX 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 7
Drywall; Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVA S4
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral TAW
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
RoughAiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
LM14 Notice (Perm) Wdl(// 7
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