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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
/ 7.1 i
/Date �. "' Signature of Contractor.
OWNER -BUILDER DECr ARATION
I hereby affirm under penalty of perjuN tha//t1l��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:
Carter Policy No.
ZENITH VRS, -CO.
(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
ubject to the workers' compensation provisions-Of�Section s(aFle Labor
Code, I sh I f rt).iwith comply with those-provlsil 1715
Date: Applicant
Warni g: ailure to secure Workers' C •�tiesand
coverage is unlawful and
shall subject an employer to criminaLpenvil fines up to $100,000, in
addition to the cost of compepsailon, 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 c
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 rep resentatives-of'this City to enter upon
e above-mentioned property for 'ps�ection.pGfp so e , ✓"^
Si nature (Owner/Agen Da ?Zit
BUILDING PERMIT PERMIT# CO
1,105-080 5150
DATE VALUATION
1 �y'5406,637.00 LOT as TRACT ��k �i
ADDRESS roi 1)631),-4ilrL'�r11°: CISC{L�lt, JOB SITEPN
�6
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C'FN'1UtY CE�Ui'�ir4A1, C �PVAL 1tJNITiFS
I 5�5 S o Sr 42W
1535 SO. "D6 .�"t`t�l T, ,ST'S. #200
SAN 13ERN��ii:D[NO <;A 92408
SAN BERNr1.t2J INO CA MOR
f'9(f l - 9 -6002 C F3I,# - 2120
USE OF PERMIT
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13,S : E aF :it1M PLAN 'T`1''P .
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(114V 39-318
i4f ii ttt�;Idic;, t, t ul 1'}T- f 1r:i2Ypc�i 1 5471,00
161-t ow=' 20-li 0 S11 ,90
i�t.,Z!.F1�1L�llN(� T�'}�• I. T! 1. Uf3t)-d i.!�•f}EH) $127. �C►
'i'1)j�tt i tUf 1t°i.rStJ i'i.tc IlCS11) 10!.OP0,141 IVQ Ct61.�F
.011Ai)JINO:f FIX .1,01-f�fll -121000 Vo tett
AWl' I.tJ M!?i3:(.I Lsl,( fia - t;<k.51% 701.90)(125:5-tIOU
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€t1�=tx �'!'r, a c)NS"1'.f f #f: l'iC7N, A[! I .►;�s +f i±�'��.h:
$3,440.18
LESS S ME -PAID FEES
p 11997
�4 W
AUL
$3,4440N
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PBY
RECEIPT
DATE
DATE FINALED
INSPECTOR
y
NTROL#
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & FootingsDucts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing Q !d oL
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
POOLS - SPAS
BLOCKWALL APPROVAILS
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 AFHeater
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
COMMENTS:
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)