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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
/574121 A_ W1/97
ate r L Signature of Contractor f Vh
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) Inas 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).
( ) I, 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 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:
Gamer Policy No.
- :iI'iyi'i:i�iiif^ l:•1dt,+?�=9i;
(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 of Section 3700 of the Labor
/Code,.[ sh II forthwith comply with those provisio • s.;l
V Dater Applicant—
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
•& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
t� above-mentioned propert/for insspecct�ionlpurpoose's.
vSignature (Owner/Agent) 1�l%C Date
BUILDINGPERMIT PERMIT# CONTROL# '
DATE 3110/97. VALUATION S-16.340.00 LOT 9703-036TRACT 4797
JOB SITE
ADDRESS 4$.190 ut;r� RI' SANDS C APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
C1�P3'11J��•1it�P:tE;�a
1535 SOUTH D 51REL1"1' #200
SAN HERNAFt.If?INC) CA 92408
USE OF PERMIT
POOL
fICK)1L ANI) SPA.0N07
POOL ANIX R PA
73-011 COUN'MY CLULA DRIV1:, VrE,14
PALM DESERT CA 92!60
(619)!k46-40:32 C1R1.# 10111
if'.3-10.001,5
ES:CINItr�ICTffNdON
�'�•�.t�r ra�r��. r.lfr �t�l-�f�-�a��-�1� sr1�.+r�
C( )ht`'1`i7tICT! 0At hF !1180.00
Nll✓c;1: A.NICAL Fr - VC 0L. $24.0)
i i:C"!'It1l Ai i 1 :--1'4�t3L W11-0G�-�i'l1-0(N) $i 00
P1 -I11 VIRING fN13--1't`)QL 1014" -419 -OW 12'1.110
RECEIPT
Na �a
StJF'�1k:)'i.',A1 •• c�._;1t�`�i"tt11t:'1lt�N 1>�I):} 1)1.At� C:}•11;C1C
TOTAL #+`1 «5t 1)t) 'Yl?W
.W
BY I DATE FINALED I INSPECTOR
I.6,3_;'L,00
$19100
S0.00..
$393.4110
i it
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs -
Fors & Footings
Slab Grade
Steel
Roof Deck
OX to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wail Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
POOLS - SPAS
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
PLUMBING APPROVALS Gas Test -
ric 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
I -*// AA A
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
7E
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