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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 41 13
Date / Signature of ContrartoAr
j OWNER -BUILDER DnEdARATION
I hereby affirm under penalty of periuryrthat I am exempt from the Contractor's
License Law for the following reason
( ) 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).
() 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:
Carrier Policy No.
ZF11111TH INS, Co. Z0421166902
(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 proisiorts of Section 3 •0'orthe Labor
JCode, I sh I forthwith comply with.trovi n'� -
Date:• �%���`�APPlicant _
Warning. Failure tO secure Workers' ompensatio caves a Is unlawful and
shall subject an employer to V. inal p tt'efties�il 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 ion his
application.
1. Each person upon whose behalf this applicajion'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, indemnity
& 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 property,for-iinissTieeectitiiioonn..p'.�u"rpo es s.
//-,j. . -- ...._ Date
Signature (Owner/Agent) •
2
BUILDING PERMIT PERMIT# CONTROL#
q71194182 515 2
DATE7/1`/�VALUATION i�iZd;f I,40 LOT 24 TRACT 21E�jS
JOB SITE 4V
ADDRESS 45-05 DESCRi�l VILOUR
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1 ONV ASSOC
CEN'11,11RY C ROtiVELL L;l.)&IMUN1THIS
W5 S: U 5.x.1. ! 200
153-5 $U. "1Y' S"1RE 'r, SI -E.,11200
SAN.C3MARDINQ CA, 92410'8
SAN BEliN.ARDINO CA. 92+108
(909)1 1-6tlt)7. ( U-0. 2121)
USE OF PERMIT
T0.PAZ 1:!L AN 5XCY2.PLAN 01EC1 .'E`IrL^• KWIXED BY 7Wd>:'oil (VIi.li:TPLE-
ISSLIE' Ula SA(V E PLAN `I°Y-073.
7,'i�..i;t; r OCiNu'S`RUC'i'.iON +l'
POR. (Ii1j.A'Tlo 63.(sr,! .11+
576.00 V
E18111.1hiXfEV CMT- OF CONSTRUCTION
PLAN CHECK FIRE 1.01•-000-439-37.8 $1-53.63
CC�1+1�?'I'12i',IC":r':t:t:�t�t 1^1'3 I0i!-(3ta1?-418Ti�A `372?>�
E�i��kirv:l�c�A1> ia`1� �o:i•'oc�:-.��1-txx� �-r��o�u
.
r 1iC i"IkiCf1[, lri- ". 101-11XA-421G-000 ffi13238
P [:LIMBINCIFFY, . 101 -000 -40 -Wo '6.167.2.4
wi'.P?.1NQ k1),fl.t-M FRI... - K6 SID i W-4)(IO-241-000 V147
GkADING FF,V, 101-000423-000 �xn.ira
At T IN I'MIff.lt",.-PLA(X.: 8 - ROSil: 703 -W) -2$,5-W) 501.71
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C� CO:NUR_t!i"TION ,AND PIAN. CHECi�.
�.gtLESS PRT�
��f,l.)®„i�
J U L 01 1997 -t n ' 1:, ►:� �a. ,r.F, ,� �� . tvo�v
S4,140J6
kd•, dip 8 6
i
RECEIPT
DATEBY%
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade a
Return Air
Steel :
Combustion Air
Roof Deck
114Exhaust
Fans
O.K. to Wrap
41Y
F.A.U.
Framing
i
Compressor
Insulation
Q
Vents
Fireplace P.L.
r
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
D
Drywall - Int. Lath
BLOCKWALL APPROVAL!
Set Backs
Footings
Bond Beam
Final
. PLUMBING APP VALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans 71
Sewer Lateral Z21#-. 11,4
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
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
COMMENTS:
POOLS - SPAS