9705-084 (SFD)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 .t'W8
/D,atet Si nature of Co tYact- g 2t
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perju that 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.
ZAR41,11114 1U.131 CO,
(This section need not be completed if the permit valuation is for $100.00 ordess).
( ) 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 �_Sbould become
object to the workers' compensation provisions of Section' -3700 of the Labor
Code, I shat orthwitIn comply with those provlslens
r
Date: s Applicants` `
Warning: Failure to secure Workers' Com � ensation coverage is unlawful and
shall subject an employer to criminal Workers'
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 persorLat
whose request and for whose benefit work is performed under or-pursuantito
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 property for insp'e`ction purposes.
�K
ignature (Owner/Agent) Date
A ?_L
BUILDINGPERMIT PERMIT# CONTROL#
9705'045154
DATE -y/1 VALUATION LOT .. TRACT
JOB SITE.
.ADDRESS 45-03# DE'SEWT VIE COURT
APN
604-331-$3-'.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
T611 +r Assoc.CENTl:
RY �:ttCa�'� t,(. COt1tt4L�FJ1'1'!ES
35 S 0 91, 9200
153 mei). ".U" mFer, ,5 rk noo
S.AN IBERNA.lt:1�► NO CA 92409
Art F 1 RNn1t131N0 C ! 92408
(909)8'1*00.r CBL# 2120
USE OF PERMIT
`1"itACT d.ONSIRU 1IGNI 1,433.00,*"
i�uRt,.t1Cf'A3�U tjJ.t3w+ S3^
(7Al�t\* i4%G At�i:'t�Fi'C 420.00 51'
870174.40
-1LA_Nf;`.f4lw't'X,FEi i, $1195.77
Q 0N_3OIt1(7,rr!0N;ti'tC, 301.000-J18-000 1595.f£t
N&-_' IAN" [CAL VT'.1 1Ot,vi1(10-471.001
i11€ 1 t"1'.�'1a AL h1?t's 101AM-420-00 $1117.00
Pa t AJf$.1 G� f J;' . 1r»4 -lora -11 9...000 a fns.
S t't 10-Y.P.oN f -'(3F, - RY-T-rte it`1.-i)(10.• q} 011f1. ��.''
-CI1'kWN %17t ,s; lCf l_000-`12;3.1100 &20,01)
WIVI:2riti`t`Et(1G;1'tik8114i 22.25.006-41.3-142 541935.99
k
LESS PRE -PAW l -EIS
$0.00
,1UL ®1 1997
fbi l :<di.. ff' �IiR1ET %'13:11,8 01IF N41W
$3,154.
RECEIPT
DATE
BY '
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR.
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Root Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath p
Drywall - Int. Lath d
Final
Final
BLOCKWALL APPROV S
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
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'
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