9705-086 (SFD)LICENSED CONTRACTOR DECLARATION ii
Cf) I hereby affirm under penalty of perjury that I am licensed under provisions of
1-- ' Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
NUJ Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
LU
Z �te �� Signature of Cntractor
, OWNER -BUILDER D:ECLAON
HLli I 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).
Cr) () I am exempt under Section B&P.C. for this reason
rn
N Date Signature of Owner
O N
Q)
Q WORKER'S COMPENSATION DECLARATION
O Ir I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
XLu � compensation, as provided ,for by Section 3700 of the Labor Code, for the
Oro J Q performance of the work for which this permit is issued.
Q C) (x) 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
H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
cI�D.O 't i.0-12.(k:k1w.
J (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
/ode, I shall forthwith comply with those provisions.
Date: -VA Applicant ✓ """"�.
Warning: Failure to securesWof a s' Compe,nns�saatio coverage is unlawful and
shall subject an employer to criminal pnaft'es and civil fines up to $100,000, in
addition to the cost of compen a io damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made& each p meson at,
whose request and for whose benefit work is performed under or pursuant to ,
any permit issued as a result of this applicaton agrees.to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.-.
2. Any permit issued as a result of this application becomes null. and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
Signature
e above-mentioned properttyy�f�or iinspection.purposes(Owner/Agent)��'"'- D"ate0IZ�"'!
BUILDING PERMIT PERMIT# CONTROL#97os.096515
6
VALUATION �}i.;)LOT TRACT �
DATE � J Ile,
ADDRESS 4a-4r1's1I6IJtf SEIR` VIEW JOB SITO
W �.1 uRT
APN 604. 31_$Wr.
OWNER
CONTRACTOR/DESIGNER/ENGINEER
"t0PJkZ ASSOC
C1'N #Y. RY C;.t'.GWT1.:v'C��f�1tlAjf"t°3�
153.5 S 1) Sl' #200
1535 SO, "L7" S.f R. rl, SCI~. f#200.
SAN f, ERti}h1.WN0 `'A. 92409
SAN BERNAMNO CA. 02408
(4491 R1:�6ti07 CRIA .2124
USE OF PERMIT
>d
1.30S]IJEOF SAME P6AN ` YPE,
TRA4:'.i CONSTRUCTION
[''t�1¢t f{Lf�A"i`ttri 63.00 A!
<;.l d'A.47'k�C;'�►Kl�C))t'!' 576.08 S
124,691.40
Ora9Ii=!'laUC;T10N�MT.' 101-0flKJ-4tt9-�iytn0'
Of -0004,20-000 $13238
f"+f:(JWit*G FEFI 1At-f.)d)414119-400 4;161,25
(t c�rWYri0N l.mi,.Rr.810 }Q1.��tuJ>?•1s-i10!) St�;1'
0RAV) IU 1:11" mi�1-A`X1-l�3wf?� $s0.11�
f tajl ii.A t' taC`�"(�afif'. is iE f 225,000-443-34.. :G,
ART 11414JOL1C� PLACES - Rr-M1, 701.000+755-00 S61'3
�6��•.��'...r�,.f'F �.�! �I`f���� {r �.s����Y ��t� a���J�P ^ ll���\M�
5`�p f �i.0"�,f
uss kE-P.r'ki:f) mm, S
80.40
J U L 01 1997
CCN OFF-�
RECEIPT
DATE ;,
BY
DATE FINALED
INSPECTOR
k
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
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation / G
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 a-
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
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: