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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, -----,--7..
71.41W a HM91
�>/. Xw Signature of Contractorr__�_�,_���'_____-__
ate
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of pe rlu del -am exempt from the Contractor'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. fo,r this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarat.i.ons:
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, f6r.the
performance of the work for which this permit is issued.
(y
�) 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:
Cartier Policy No.
ZENITH INS. CO. 2042106690 1
(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 provisions o2!,Section 3700 of the -Labor
Co I de, I shall forthwith comply with those provisiotis.
V/Date: ALI - Applicant—
/ 71", 1/ .1 - I
Warning: Failure to secure Workt�rg"Compensaiion.coverage-is-ohl�iw-fGl-d-rfd--
shall subject an employer to criminal penaltiesand civil fines� up to $1 00,000,.in
addition to the cost of compelnsation� 6amages 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 pursuant tof
any permit issued as a result of this applicaton agrees to, & shall, indemni,
& 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 informoation 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 above-mentioned property for inspection purposes�___ -
./ionature (Owner/An ntl,,:,- D a* t'e
PERMIT# CONTROL#
BUILDING PERMIT 9 6 12- 1 .94)
4 8
DATE VALUATION S101,276.10. LOT vs TRACT ,4,5
JOB SITE
ADDRESS 4 5-1144 DESERT SAAND couirr
OWNER
CONTRACTOR DESIGNER / ENGINEER
CENILTRY CR01V VLL CO3N1N,1W1,N1'1TJffi S
%C "'N'll MY cv,01111111.1. CONINIUNME's
035S0.'V.S7REF,T,&r8A1'2W -
1535,S(). 43" #200-
SANBERNAMANO CA 92408
SAN 131IRNAMANO CA 97408
(W,)381-6007 CB01 2120
11MAIN4 N1 AMMAR ASSOCLIVMS
USE OF PERMIT
8
54S9 111II AVE.
TO -PAZ @ LA 0AYNFA NOlk-efle
PLAN CIfECX II REDUCE]-) F(Nt MIJUILIX, ISSIW 0F SAME PLAN
31U%iI MNS"MUCT(ON 1.689.00 Sr
PrikCHWAS-10 106,00 &F
4K00 SF
_1.1S WED (.IIiD3T OF COMIRU TION
STIN C
.101,276.1.0
VERMIT VCR SUM MARV
PL.;W C11-ECK FEE 101 -OW-439-318 $24332
101,4110-419-000
I k V',L-KRA1QCAL R'I'S lot
101-000420-000
RLUMNING F'RES M-000-419-000
MAO
INOR A811,1(1101d, 2.1-540-iW; -342
ART IN PUBLIC PLA(PS (RIN8) 70t-000-255-000
SUB-TOTAY. CONISTIRICnON AND PLAN CHECK,
$3,504,78
LESS' PIZ-PAID IIEBS
$0.00
TOTM, PERMIT FEVS DUE NOW
996
S3,504.78
VAX-.;>
011
C�IPT
DATE
BY4�
DATE FINALED
INSPECTOR
L
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs , /
Underground Ducts
Forms & Footings el"ZY-7
Ducts
Slab Grade . I JJ 1 14
Return Air
Steel f-
Combustion Air
Roof D#ck
ExhaustFans
O.K to Wrap
F.A.U.
Framing W
Compressor
Insulation V717
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
BLOCKWALL APPROVALS
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
ShowerPans
O.K for Finish Plaster
Sewer Latenal
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test AZ�
Appliances
Final
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
I Utility Notice (Perm) L,11 o4' 117 1
COMMENTS::