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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of per jur . y 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. qate
7 t,rl I t�S ri-9-1
/DatZ c r
�4--Signature of Contra tot
OWNER -BUILDER DECX`A;RATION
I hereby affirm under penalty of perjury,that I am exempt from the Contractor's
License Law for the following reason.14�1'
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-ins6re 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 w ' ork for which this
permit- is issued. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No.
"':, M 110,
(This section need not be Completed if the permit valuation is for $100.00 or less).
( ) I cerlify that in the performance of the work for which this permit is issued,
I shall not employ any persor� in any manner so as to become subject to the
workers' compensation laws of California, and agree that if 1. should become
subject to the workers' compensation provisions of Section 3700 offte Labor
Code I shall o h comply with those -provisions.
/�hwit
'* 7f "I
V Applicant_--'�
e .- � , I —
Warning: Failure to securg ��rorkers C'�'
,.��pi5hsation coverage is unlawful and
shall subject an employer to crimirial;pbn , a I ties 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 9�d 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, & shal.1, ind emnify
& 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 cancellati6n.
I cerlify 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 at(ove-mentioned property for inspection purposgFs—,--
/ignature (qwner/Ag ntl Daie..4.,4
PERMIT# CONTROL#
BUILDING PERMIT
.9612-1.47 4545
DATE VALUATION S,1,24,611.40 LOT. 12 TRACT IL
JOB SITE
ADDRESS 45-OWDINERTSANDCOMr
APN
QW290-037
OWNER
CONTRACTOR / DESIGNER ENGINEER
153
1. s3. SO. "D" STki" 000
1 �,5 i so. I., D n snkpi iv� ow
SAN RKNARDINO CA 92408
SAN 8fiRNARMINC) CA 92408
('909,1391 6007 CU11 21.20
R NMIMIN ACUILAR ASSCIt" ATES
USE OF PERMIT
SFD
:V1_W11ASSVR0 "K
TOPAZ @,I�AQIAWAJ40111111i
111. A14 C1YAX,'PfT.'3 OF SAME. PLAN
TR&Gr CONSTRUCTION Z073.00 3F
PORCHA'AY10 63400 SF
0ARAOU' CMPORT 57619)
'IS'f , 1,1k*ftr 4ff C()- 49- V
Ifo f) CO3 . OF N. fl,
.2-40 qn.m
M-14"vc-P, summ'Ally
PLAN CKICK Me S276,D
CONSIRUCVON FEE 101-000-4 k"()
, 0 S727,00
N.I.-CRANICALTTES .101_0WA 1_000. S79.00
PLUMINNGFRES $167.25
I- TIMNO MOTION IRES,) W140-241-000 $12.47
S
GRADING
1WVR,A.TrUCrf Ugt 225-000-443-342
AP.1' fNP0B.LtC PLr&"_'h_,S (RF -S) t, 7014)0(0.53-000 so t.rn
11CM-Trf fAL CONST R(J(,MQN ANDPAN CHE CK
$4,263.26
PAID I'Mc, PRE-PIVID FLIES
.COTM, PERMIT FkRS DIT N08V
3 0 1996
$4,263.26
�CITY OF L A ()LjJNTA
SEC IPT
�
Bf
DATE FINALED
INSPECTOR
I ]DATE
W�
1 .
I . I .
I . .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE —7
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs / / f
Underground Ducts
Forms & Footings If 1,f
Ducts
Slab Grade 4:�/�
Return Air
Steel - ff
Combustion Air
Roof Deck :z
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
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
/ / 11
Gas Test
Electric Final
Waste Lines Z14& 2
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral A
:4�
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS'
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exttrior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Litility Notice (Perm) -.71