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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,
/X-,/ nature of Contractor
a-te,, Sig
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury ttj�.Oam exempt from the Contractorls
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 o f 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 Policy No.
ZEN11111 IN& C0.
(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 subject to the
workers' compensation laws of California, and agree -that if I should,become
subject to the workers' compensation prov�i5qns of Section 3700. of.
ode I 'al Irthwith comply with those.provisions.
C_
Dat!xe Applicant—
��5�verage is �unlawful and
Warning: Failure to secure WeU5r-:k_e_rs' Corr-p,�a,
shall subject an employer to criminal p ;>.,
,enalties and civil fines up to $100,000, in
addition to the cost of compensatie4amages as provided for in Section 3706
of the Labor Code, interest an�raftorney'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 employee�.
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 representatives ofethis City to enter upon
the above-mentioned property forJn9l5ection purposes.
/ignature (Owner/Agent)r� DateA-:1A"X;-
PERMIT 4 CONTROL#
BUILDING PERMIT wo 1-148 2 1974 1 1 46
DATE 17� VALUATION . 13124,691.40- LOT:. ",1.3 TRACT 454
2 �, /Z - 7/
JOB SITE APN
ADDRESS,,
JOWNER CONTRACTOR DESIGNER ENGINEER
", IN UR
1_515SO. I'D" STIGM �511E. 0,200
SAN 13113ANARD11,10 CA. q240R
1535 SO. "D" STPLEET, 917Z,000
SAN'Sf-ANARDWO CA 92408
(909)M 145007. CBL'# JIM
USE OF PERMIT BENJAI&IN AGMAR AMOCIATA.S
-.1411) 1 5459 P.403SHRO ivVE,
-f C)Pi%Z (0, LA. QU (N -VA NOIU�E,
PLAN 5,KA
'PLAN CUECK..FER3 RYLKICUO F0RN1ULT1FqX MWE CIF SAW-. MAN
RACI'CONSTRUCTION 2, 0 1-3. (A) SF
V1'1'1.'1;Xrff1P1_Vi40 63.00 SV
GAMOSICARP0.1el' 5716 (K) Sp
EST] MATED COST OF UOINSTRUCT ION
SUMMARY.
PLAN CI.W.C& Fffi
. Wi(MOCAL VW; Is 3132.58
PLUMBINQ �V_F�S
STIRONO X,10i,[ON (to -'s)
10t-000-241-000
V2,47
10.1.000-123.000
'020.00
Ni - R A�lh 101 JRE
2125.000 -*V3-342
786.110
AJW1' IN I'LlIlLic INA0,s fRFS)
701 -000-24,550)0
UAY.l
V 1417CK
LESS PRE -PATI) FEEN
DAID
WFAVIMMM314"Cle.14 DUE NOW
DEC 30- 1996
01 IIK TA
RECEIPVII I I I!Wre �Y. DATE FINALED
E;.,
124.691,44)
$4,243.26
INSPECTION RECORD
OPERATION
DATE I
INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing gw"-O.Z�
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
A
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APkOVA�S
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 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
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
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp; Use of Power
FlMl .1.4 -7
UU14 Notice (Perm)
COMMENTS:
M