9607-004 (RPL)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
cv W Professionals Code, and my License is in full force and effect.
O ::) M License # Lic. Class Exp: Date
0W T2I fiAl o C-S.� _ 61, 8
Z � 7%7 Signature of ntracto -c
ZO ate 7-
P:
- g Co
J U ° OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) I, 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
IT
d< WORKER'S COMPENSATION DECLARATION
C:) 2 Z I hereby affirm under penalty of perjury one of the .following declarations:
U-) H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
li v Z permit is ssa e`c�; f�ty� yxor�ke�sF mpensation insurance carrier &policy no. are:
Carrier Policy No.
cb Z)
Q (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, I shall forthwith comply with'those proVi _17
✓Date: Applican%��"'
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
the above-mentioned propertyr inspection purposes.
Signature (Owner/Agent-fir !/ - - -...:Date"-'
BPERMIT#
BUILDING PERMIT3658
CONTROL#
�t7-��
3 6 5 8
DATE `71 m% VALUATION 814,0100 LOT
TRACT
JOB SITE
ADDRESS '79-320 UFSE �1 S j'REAM
APN
;OWNER
CONTRACTOR / DESIGNER / ENGINEER
01MIENP NIANNU
VALLEY PCO1. & SPA
19-320 f�liSirAZi ST'RE t\RA
d7�AA E. PALM i:t1NFQN DR. i>rl Iti
TA (QUANTA
PALM SPRINGS
CA 92264
3i(to ro I
610M393(l,
0 2 65
USE OF PERMIT
K_)UL ANU1t IR SNA
P001, ANL) SPA.
,(X)L ANTVC* SPA
L5
MIT(Vli1TEDC"V1*OFt,ONSTRUC'.fION
14,000.00
PERN111"FEF SUMMARY
p, IB:TL .' .NSI'RUC.'TTON AND PLAN CHECK
5348,45
j D
LESS PRE -PAID FE FS
$0.00
JUL 0 3 1996 'SAI: PERIMIT F EKS DUE NOW
S34R.45
BY
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
■•c
4
S
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR '
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
UndergroundDucts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
ents
Fireplace P.L.
rills
Fireplace T.O.
rFans& Controls
Party Wall Insulation
ondensate Lines
Party Wall Firewall
Exterior Lath
-Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain 750
Bond'Beam
Approval to Cover
Equipment Location
Underground Electric.
Underground Pibg. 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:
Oita
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