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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurythat 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
? jd 137
Date _ Signature of Contracot" r
( OWNER -BUILDER DE'CL`ARATION
C
I hereby affirm under penalty of perjury 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.
'LIEsi4TH INS. CO 2042066902
(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 orkers' compensation provisions 3700yofthe Labor
/Code I, all orttat h comply with those provisions`
J Date: f� r , Applicant
Warri n ' : Failure to secure Worke_rs,_,G; pensatlon Co e' CT rage is'unlawfUl-and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth ons his
application.
1. Each person upon whose behalf this application is made & each person}at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
/te
struction, and hereby authorize representatives of this City to enter upon
above-mentioned propertyfor inspection purpo s.f '"nature (Owner/Agent) �%"" Date/ r
f
BUILDING PERMIT � - PERMIT"�-. °°NTR°`#
5:5
DATE VALUATION 'LOT TRACT
t, 1,'` i'9 ?3
JOB SITE
ADDRESS 4&116 0""f VIM C MAT
APN
" -331
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'IUMASSOC
CENT KY CR ELL CXA MUNMES
1533 91) ST #200
15315 SO. "DR 9TREET. S'M. s2,<1ti
SAN HERNA W) ?'A 92408
SAN E3i1RNARDINO CA 924M
(4Mfo~4} 1 41A7 CRL# 2120
USE OF PERMIT
3140
I c (JALL KAAt 5". PLAN 016(X ifib 1%8[3ii W iii 75% FOR 1AiJi."i'11IX
I,S3 h (W SA AIA KAN'3'VW.
TRM,'r (Y)N9T1tLXMUN 2073.00 9F
PCRLIWA' u 63.001
OARAOHWARPORT 576.00 3F
W'iTlklrilT1' D ('(W OF CONST'R(fMON
124A91.40
P IIZM1'1" 1»VE S tIMMfAR
PLAN ('idtV: , F"M 1014)00-4.V-31$ 3153.63
r0NXrRiX'"i'lOtJ FEE 101-00"18-W. M 00
WICHAMCAL FEE 101-340.421-000 $119.00
1a1AV07M t`AiL FW 101 -W -420-W $132.58
P1X*4bM FM 101-000-419400 $167-25
MNO WYMN FFT - RFSTD 101.4f14-241-1?011 $12.47
MADINO FEE 1014)00-423.000 320.00
1Ns RASTRIX"rLME FE 22'5-40Q-443-342 SZ796.70
ART [N PL iKY' PLAIClIrf3 - I!BF..Sic 701,4W2MS-M 361.x3
( '{TINE. 71ON AND P1,AN f HFCK
S4,14(1. *
PAW1�1'AI,
LESS PRE -PAID PEES
$0.00
J U L 01 1997 TOTAL PE12Mff FEIM MY, NOW
K14#J6
Uk C)PINTA
r ��
REC
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
1
Forms & Footings Z 7
Ducts
t
Slab Grade
Return Air
= I
Steel
Combustion Air
l
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing Q
Compressor
I
Insulation
Vents
i
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
t
Party Wall Insulation
Condensate Lines
'
Party Wall Firewall
I
Exterior Lath
Drywall - Int. Lath
f t
Final
Final y 7
_ POOLS - SPAS
t
BLOCKWALL AP ROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
'
Equipment Location
;
Underground Electric
i
Underground PI . Test
Final
Gas Piping
PLUMBING APP OVALS
Gas Test
Electric Final
i
`Waste Lines &V
Heater Final
Water Piping
Plumbing Final
j
Plumbing Top Out
Equipment Enclosure
-j
Shower Pans
' O.K. for Finish Plaster
!
Sewer Lateral
Pool Cover
'j.
Sewer Connection
Encapsulation
Gas Piping 41I
Gas Test
Appliances
I
Final
'. ¢
COMMENTS:
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
Utility Notice (Perm)