9612-141 (SFD)LICENSED CONTRACTOR DECLARATION
_U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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C11 LU Professionals Code, and my License is in full force and effect.
Z) C') License # Lic. Class Exp. Date
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W Xt N 7
'70 1-/ ,,r
Z r� /Dat Signature of Contracto
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�Z C3) OWNER -BUILDER D VAMRATION
UJ W (0 1 hereby affirm under penalty of perjur xempt from the Contractor's
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License Law for the following reas n:
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Z 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).
ce) I am exempt under Section _, B&P.C. for this reason
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C\I Date wner
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a- < WORKER'S COMPENSATION DECLARATION
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0 cc I hereby affirm under penalty of perjury one of the following declarations:
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F-; 0 1 have and will maintain a certificate of consent to self -insure for workers'
UJ compensation, as provided for by Section 3700 of the Labor Code, for the
0 _J performance of the work for which this permit is issued.
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< I have and will maintain workers' compensation insurance, as required by
C5 0 Section 3700 of the Labor Code, for the performance of the work for which this
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0) permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
cb 0 ZLN1714 INS. (30, �V4 2k" W I
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< (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 4hat if,1,81�ould become
subject to the workers' compensation'provisions of-Seiftion,3700 of the,Labor
ode s 11 forll v 1:, comply with those provisions.
D te: -Applica�t
a
Warning: Failure to secure Workers"tompensation 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
const , ruction, and hereby authorize representatives -(5f -this City to enter upon
/thig above-mentioned property,fbr�in�pectiii npurposeg.
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nature (Owner/Agehf) Date
PERMIT# CONTROL#
BUILDING PERMIT
DATE VALUATION LOT TRACT 51310W
JOB SITE
ADDRESS 4&4" DR54MT U" 01HIRT
APN
a
OWNER
CONTRACTOR DESIGNER ENGINEER
CEtMORY rROWELL 0.)MMUNMES
VEIT11AY CROWELL O)MMUNMES
133,�,SO `D" 4200
133390 920D
SAN HFRNARDINO t'A 92*)R
SAN HEKNARDIN0 C`A . 92409
4 1W. 118 1 -OW 7 ca" 2 120
1WWAMIN AkAUTLAR A&;�-IATUS
USE OF PERMIT
Sill)
AVE
I (AIA4 if LA Q01N I A NKW'111�
PLAN 3XAR
PLA,N CITPXK FRIFS RM K'Fn " WItTfIRY f, "�IF CW SAW KAN
'rRAk_70.)NSTR(VTI0N 1,6*.00 SF
106,00 SE
0ARA(W.A'AR1K)RT 416.00 W
VITIMATED COST OF COMTRUC710IN
16112761111
PERMIT FFE SUMMARY
PLAN 0-W.CK PEE 10.1 -000-439-' .4 18 S243.72
("X'INSTRIA-110N F;TtV 101 -M-418-OW S6" %
MECIIA141CAL FU -*S 10 1 4X)0-421 -OW $53.50
r4Ak-1VJCAL I�MS 101-000-420-OOG 104
PLI"4131NO FF" 10 14*041 96-M $148MO
TMONO W)TK)N (RFS) 10 1400-2 41 -000 $10,13
ORA"NQ 101-ODO-423-M S20-00
11*1_"1Tr(.K11URE 22,5-000-443-342 $1246.99
AR;r IN PtfMW PI-AC&S IRES) 701-000-235-M
R11B.1y)TA I., r(R4,,,TMt.rn0N AND MAN rf4FCK
T3,3043ft
LESS PRE-PiUD FEES
P10A I D
SUG
TOTAL PERMIT F1904 DITF NOW
!U,%4.79
DEC 3 0 1996
("'IT OF I A QUINTA
-Y
DATE
BY
DATE FINALED
11, !k-ql
" 1 *11
-,-A;
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade A
Return Air
Steel .1 1
Combustion Air
Roof Deck -7
Exhaust Fans
0. K- to Wrap
F.A.U.
Framing -07e, —g
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
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
I I
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
Final
Utility Notice (Perm)
COMMENTS:
I !