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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 Exolb ate
10/3 107
/,.,e171k7l"Z_ nature of Contractor
Dat 41-9
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury thatlll&m exempt from the Contractor's
License Law for the following reasbri: /Y
( ) 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. 3100 of the Labor -Code, for the
performance of the work for which this permit is issued.
K) I have and will maintain workers' compensation insurance, as required by
S6ction 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.
7_91NX MR I NWCO,
(This section need not be completed if the permit valuation is for'$1 00.00, 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 agrep,�that if I should become
slect to the workers' compensation provision
,�;of Section 3700 of the. Labor
t t - ose ons.
Cdcle ��ithcomplywith h -y" 'isi
,gov.
v6ate: AeApplicanj
Warning: Failure to secure Workrrs' Compensation coverage is uniawful and
shall subject an employer t riminal penalties and civil fines up'to $100,000, in
5-c
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, r
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
constr'6ction, and hereby authorize representatives -of this City to enter upon
/thabove-mentioned property for.in's"p.ection-:-p�u'�rp.�oses.
VSignature (Owner/Agent)!� D a te--'Z/' 14/_1
PERMIT# . I CONTROL#
BUILDING PERMIT
9431-139 4537
DATE VALUATION &124.691.44) LOT. I TRACT
9.A 5
.7.3 - -1
JOB SITE
ADDRESS
APN
604-280A)45
OWNER
CONTRACTOR DESIGNER ENGINEER
A..1 k 1,4 L4
Tuln ROWEL]
UN J
0
SAN OURNARDINC) CA 92408
SAN BERNARDINO C -A 92408
(9003141-6007 CB11 20710
i APQ AM11`4 AMR,AR AWX tATEN
USE OF PERMIT
SRI[)
54559-PASSEKO AW.3.
PLAN CMECT.. FEE.3 110 )UC Mi F01t N411L'FWLI� IMM, OF, SiW_'.R KAN
1.3r.
GIM(AGFICARPORT 5X00 sill
OF
ft, Jt,",%, 5.6. k4w -_Uk 'J.1,
k
,I ILAN 01EIX K,'61 101 -OW -419-318
M14M. LTC, rION FEE.-
MPR'HAWCAL ItIES .10 1 -000- 42 J -000
mxcl $132.58
PWN11ffiiKG PFJ3$ S16712"S
STWMG NfaY10__N (RES) $12,47
, C
ORADING
2257000-143-342 86, 7 0
ART WKIRLIC PLAC�FS (Ikf-;S,) 701-600-255-000. $61.WL
41 C0'NTMR'(,1Cf tONY A N 0 P! -A N CJ I E CK
$4,263�26
PAIDY-y-r-11
LESS PRE-PAIDIFTES
Woo
DEC .3'0 j996 TOTAL PERM], -FEV,8011FINOW
CyTy OF LA QUIN-rA r
RECEIPT
DATE
DATE FINALED
PECTOR
1.13Y`.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1 11
Underground Ducts
Forms & Footings If -7 —1001,
Ducts
Slab Grade /oll, /"q
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
04
Final
Final U�ZIEW W,-
POOLS -SPAS
BLOCKWALL APPROV�LS
Steel
'Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbq. Test
Final
Gas Piping
PLUMBING APPROVA S
Gas Test
Electric Final
Waste Lines �4
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS.
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
LItility Notice (Perm)