9705-077 (SFD)N W
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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
"'14 Rtl i3 0807/te Signature of Contra or v
OWNER -BUILDER DEEC/L'AA I
I hereby affirm under penalty of perjury Sha exempt from the Contractor's
License Law for the following reason;r�
( ) 1, 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:
Se( ) I have and will maintain workers' compensation insurance, as required by
ction 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.
ZEIN ITI iNtiu CO. �t24 Cr�9G2
(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.l should become
subject to tl�e orkers' compensation proyisio s of Section`3700,oPthe labor --
Code, I sh I f liwi comply with those provisions..�""�✓""��
,Date: Applicant �/'"--
Warnin . Failure to secure-WZ'o e s C6. pe sat overage is unlawful and
shall subject an employer to. criminalrpenalties and civil fines up to $100,000, in
addition to the cost of compensal on, 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 rel�g-to the building
construction, and hereby authorize rep er sentatives of;dhis City.to enter upon
th rabove-mentioned propertyfornspectio , .Bnr oses .._'"`r
nature (OwneP/Agen � Date
-
T # CONTROL # .:
���-�t%7 TRACT
BUILDING PERMIT FERMI
DATE VALUATION S1 x04 �'d LOT 19 3 �.
1 (,l
ADDRESS 4 .5-155 iJES*,.RT VIEW COURTJOB SITE
APN 1104•-331—
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'i OPA?.,.t�SSOC
BUILDING PERMIT FERMI
DATE VALUATION S1 x04 �'d LOT 19 3 �.
1 (,l
ADDRESS 4 .5-155 iJES*,.RT VIEW COURTJOB SITE
APN 1104•-331—
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'i OPA?.,.t�SSOC
CE�l"tiT1.Y L";i�C1l�.r ILL'l".C'a����St.I��Rl1't'� _s
1535 S 13 it �d00
1x35 Std. "u" S'r(21•,la 1, sn.. Iu'��CiQ
.SAN lei?I1.AJx�kl.D•1NO C.A. 9'2408
SAN BERNARDINO CA 92408
(909)381-6007 C"M.1f 2120
USE OF PERMIT
ljwG V .�ix%
TPAt"`4." i;�'iNS'I1il3CIICIN 2,073.00 f"i€�
1oi�C1311�.A`flo 63.00 W.
QA:fi,k01.-JCA121't:IR $,76.00 `SF
'`'D COSTter' c�ztiS �'�:97C13
t'1�:RJ'1�'I FEE Stl,I.t►'i'�t1rRY
Pf,AN 0,fMCK. FOP, i £1i.-X100-�J,;9-31£3 M 14. it
i 01 y00t.'•-415-000 $?M7.00
irlO, l��xf.AD..V.1%, .... 1.01•OD0421-000 X71>.t3Q
lt.l.€CTRICtt€:'t�AS lel �iiJ{1-4�t1-L�ih3 S,1315S
PLtlibf ts'it+f%� Ff 101-000-41.9-01DO $167.7.5
STONG .1�1�Ji"ION .ME .- RPT7ill 101A10-:241-000 $12.47
QUAl;ANG k'. X 101-600423.000 $29.00
1 �E�.1$A8TR.UC 1*U. H •F:f�ls 22,5-000-443-342 SM"Jiv`Fi.770
A!R`1: It�T JPQS;.f.CN K,i�CES w R.E.1,.Cf; 70'1-NW7.55 000, t61',73
t
1�i ,r
64{ `•Si,? 'A"!J-, islX4P 17K!J( 1110N :AM :P1A.N d.��..1.>yCK
q ,t. �7
$ .601,?4
LESS PRE,7VA.�1 FEES
PP� D
$0.00
to cE1 .:!'.ir",Ja1�Q M:1' ' EMS: o19 tl i!: tvQlVtr
.$4,601.24
J..UL 0 1. 1997
.
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RECEIPT. - L:
,', : -
.DATE; _: J
BY j °'
DATE FINALED
INSPECTOR
• ad
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
j
Underground Ducts
Forms & Footings
Ducts
Slab Grade
/
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
/
F.A.U.
Framing
Q
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Q
Drywall -16t. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)