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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
71498
ate /7
ignature of Contractor",��
OWNER-IBUILDER - :CLARATION
I hereby affirm under penalty of perjury tha�t__,,.,ahll�empt from the Contrdctor'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 Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will rdaintain a certificate of consent to self -insure for workeW
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
S'�) I have and will maintain workers' compensation insurance, as required by
ec'ion 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.
ZH",NVr14 [N3. Co.
(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 subjpct to t he
workers' compensation laws of California, and,abree that,if 1-sh'6'uld become
subject to the workers' compensation proVigi�*ns of Se ' ctioii'3�00 of the Labor
CAB, I shall forthwith comply with tro�e provigi��s
V6ate: - A iplicarif-
Warning: Failure to secure Workers!'Compei6sation coverage is unlawful and
shall subject an employer -to crimifial,pienalties and civil fines up to $100,000, in
addition to the cost of compen's'ation, damages as provided for in Section �706
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, incler�nify
& 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 representafijyyes�6flh�is City to enter upo . n
the above-mentioned property for'inspection -purposes.
/ignature (Owner/Agene_� Date -71AII*-
PERMIT# CONTROL#
BUILDING PERMIT %12-144 4542
12307413-4
DATE VALUATION $124,691.4Q LOT 9 TRACT.
SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
CDMJRY CROWELL COM MIJINMIES
.153_5 SO. "WSTMU�r.�STEI #200
1535 SO. "D" SMEET, 81E. #200
SAN BERIKARDINO CA 92408
SMW BERNARDINO CA 92408
(9W)38J-6W-7 CaBL# 2 U 20
AUNJAWN AGURAR A,�c*K)CLAII'S
USE OF PERMIT
S -PD
5459 PASSERO AW7.
TOPAZ Qqp LA-.QMNTA NOR'A-.
PLAN 'v5XCR
PLAN 0-113,CK VC17.13REEDUM") F0kV-U13IPtE, U4.1 -AR. OF SANIG PLAN
TRAK"'T ODNISTRUCITGN V 3.00 SF
POROtWIJATIO 63.00 SP
QAftok(k0CARP0WI` 57(j.0 3F
I T -1 1XV I, 01r CONSTRUCRON
IN I A, A: f 10, D
PC, A All i f 'it -if, f1l 8 1 J IVI MAR V
PLAN 042T.X Ir M- V, 6,31)
ICONMIRUK71110N F FIE 101-000-4118-000 S727.00
FELS 101-000-4:241-000 $790
WXC-.r�RXAL f?WiS 14140-420�000 .54
PLUMOIN(J.- FllfflS 101 -MO -419-000
STRrR40 Wyrfn'N 00118� I Q I _W -d2 4 � _001f) $12,47
2IS-000-443-142 42,186,70
A R'r J N: P U B L 1 1 IL A.Cl iS (R (T.",
J
.0 TAf CONISTRUCHON, -AND PLAN CHFCK
$4,263.26
vAl U' SS ME -RAID FE, -L7S
$ 0. &1 0
DEC -3.0 1996. 'I'MAJ, PERM 8 DGE NO
$4.263.26
CITY OF LA QUINTA
J'RECEIPT
DATE..
BY, J
DATE FINALED
INSPECTO R
711
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE _—TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs / f
Underground Ducts
Forms & Footings 17 4-11-
Ducts
Slab Grade W,4, / /j
Return Air
Steel // 71 / Ir.17
Combustion Air
Roof Deck ;WW, f -7 L11
ExhaustFans
O.K to Wrap f&", 11
F.A.U.
Framing 46=
Compressor
Insulation YIAII—ez L14
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath -7
Final
Final
POOLS -SPAS
BLOCKWALL A�PROVALS
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 zz.!��
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test z
Appliances
Final
COMMENTS�:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
E)derior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final ,0 /4,e 4-4
Utility Notice (Perm) 0'(// 7