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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.,
7141916 1 6 ;-
I, ignature of Contracto
OWN E R-13 U I LD"DECL`A6AtION
I hereby affirm under penalty of perj'urVhat,,I,am exempt from the Contractor's
License Law for the following reason:,,,%,#�'
1, as owner of the property, o/rmy 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
I -
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following cleclarations:�
( ) 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.
SZ6�iI have and will maintain workers' compensation insurance, as required by
on 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..
2U]THTNIS, co, - 1
(This section need not be completed if the permit valuation is for $1100.00 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'igree. that if,l,s6ould become
subject to the work9r's' compensation provisions of Sectid-n-3700 of the Labor
dide, I shal 4b ith comply with tho'se"provisions.
V ate: I _A&licant
Warning: Failure to secure Worke�r�s,',Gdm���ve rage is unlawful and
shall subject an employer to crimin,al,penalties and civil fines up to $1 00,000� in
addition to the cost of compeps6tion, 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 pursu ant to
any permit issued as a result of this applicaton agrees to, & shall, inclemnif;
& 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 f80 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 upo
the above-mentioned property for inspection purposes.
/innature (Owner/Anent) Date'
PERMIT# CONTROL#
BUILDING PERMIT %17,140
DATE VALUATION S,124,691440 LOT 5 TRACT .5138
JOB SITE
ADDRESS
APN
604-290-044
OWNER
CONTRACTOR DESIGNER ENGINEER
CE1111pp"ifty C1110VIVEIA, IMNIMUNRI'lis
�X,L4 SURZY CRIONVE11111 CON111AUNWITIES
35 SO. I'D I MEEP, S.F.E. 9200
SAN RERNARDWO CA 92408
SAN SERNARDINO CA 92,408
USE OF PERMIT
5 4 Y-) I AS4WR 0 h.
�LAQONT: NOML
TOP& A
PLA34 5XC
P L AN CHECY, IFFS.3 fMDUCFF� FOR WLTIP1.6 ISS UE OF S AMG PLAN
TRACr CONSTRUCTIC�NL Z073,00 SF
63.00 8F
(;ARA_0,WCAf(PCJRT 576,00 8V
ST Olt COW.H.UCTION
16STIATATIED CQ
J 244 1.40
K AN '0111JECK FEJ-3 $276_9
(70'NSTRUCTK e 7. M_
ON rfF $n
IWECRANICAI. FCAS'S 101 -GA) -421-000.
WECIRICAL fl,'B
101 -OW -419-000 $147.25
,Tf,R0_N0 M(Yf10N (Rrf;) V2.4.7
7.8(JRE*.,Ri 701-000-23540)
SUB-10T.A!, CONSTRUMIONAND.PLAN CHECK
r
M A LESS -PRE-PAID 3EES
I ND
$0M
DEC. 3.0 1996
CITY OF LA QUINTA
,RECEIPT
DATE
B,?
FINALED
]INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR.
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade �7
Return Air
Steel
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
Drywall - Int. Lath
14
Z,
Final
Final wl /,/r/ '14
BLOCKWALL APPROVA�S
POOLS -SPAS'
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
,Equipment Location
Underground Electric
Undergrouhd Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
.1 1
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
'Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans 4:7
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS,
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub. Panels
ExtLirior Receptacles
G.F.I. I
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: