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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
/ 1 183 4tLti:3afty
Date Signature of Cori act_
OWNER-BUILDEIIECL ATION
I hereby affirm under penalty of per<,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.
9�1 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:
Cartier Policy No.
(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 sh>ld-become
�bject to thy' workers' compensation provisions of Sectioh .700 of the Labor
Code a Yfo ith comply with" those p�siens
Date: 4, Applicant
Warning: Failure to secure o�' C me2Lsaxlgaearerage is unlawful and -r
shall subject an employer to crimrn I -pe alties and civil fines up to $100,000, in
addition to the cost of comperls9fion, 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 ente upon
thdabove mentioned propert�for raspectionpurposess..Sinature (Owner/Agent-�' �� Dat.-7///WV
BUILDING PERMIT PERMIT# CONTROL#
>70115-11%] 5151
7�a� VALUATION LOT TRACT
DATE t/1 7
:4:111l4,27CP,lllf .�; 7,3+��t
JOB SITE
ADDRESS 43-03 YY 4�i li 1�,YIf+;W i.'��Yiii'II'
APN 604-331-04
"OWNER
CONTRACTOR/DESIGNER/ENGINEER
'!;t:��-1».�.1..;�Cr?(1�t1r+91L';'!l�'+'>i�:;a
I S33 S .t.i 1 i`" 7i c.M,
1 533 90. +;Dn O rld:.U,. �I: Yi 200
SAiN RHRNAR,DINf;_D CA. 92408
SAN fS1s1Z1efARD IN0 C—A. 9240R
(909YAP-6007 IM0
"
USE OF PERMIT
18,'41111 OP SAME f'I,,AN `I AW,
'. RA4 r C;tRS'2"ki:k!€:"i°ON f,C,89.00 3
"tCH&J%, i0 1.06.tfo
0A1tAQWCA.irPO ICT 416.00 SF
WIrDMATED COST OF Ci3,'d'S't'it.UQ-TION
101, 76.10
T,f..AN CKCK FF113.
S, ONS'Tdt[M110-J IYPE 1014K)Q-41840) X6.50
NWCf'tANTCAL .FEE '!W -OW -421-000 S53,S0
f�l:,uAi? If+tc r -FE. ' ' " ' 101-0004194)00 $T.�tt4.tJ0
ST01N0j1 (yFT0,X _,M8 -T) TQi"-OMMM-00 �1.11.ln
OPLA 7iNO VFJ 1014*0423-000 Sat3.s
19f, RANTatt ,"1`irfit3.PTis 22570W-443- 342
A''WfINPt:1k3f.dCPLAOF.S-3rwr,70#-00()-255-0 0 $210:00
1
�1JIKA.-'At (ZOtrTRUCVPON AND PIAN rr.�
�i,3F.44fi
J U L ®1.1997 TOTAL, P EWIT' FERS 04WINKI)w .
S3.396.46
RECEIPT
DATE '
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
P, AY 7
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
z4(&Z7 41Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
d %a
Drywall - Int. Lath
Q /Q J
Final
Final Z'
BLOCKWALL AP ROVALS
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
OX 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: