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LICENSED CONTRACTOR DECLARATION ?.
I hereby affirm under perialty of per jury'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
ltoi�107
Y Date Signature of Contractor
OWNER-BUILDER,D CLARATION
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:
Cartier Policy No.
2.IcIv`I'rlI IN;3, it`y7, ' u132Cffti3tiL
(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 .should become
subject to th Eworkers' compensation sions of'S3700 of the Labor
.ectfon
ode, 1 sall fo4hwith comply witl�hose4prov�!'si
Date:' pApplican ____ ,� ✓' ` „.. --- ----^�
21
WarniKg. Failure to secure Work eFS" 'Compensation coverage is unlawful and
shall subject an employer�,enminal 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 on hist
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 ursuant 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,�,r�ppresentatives of this City to enter upon
2gnature
e above-mentioned prope ,fo�pe'ctrpurposes. -1 (Owner/Agent �~ Datef >Or,F M
BUILDINGPERMIT PERMIT# CONTROL#
515 9
DATE AVALUATION LOT � TRACT
(� :$1(111*276.14) _tI 1330;45
JOB SITE
APN
ADDRESS 4,-1 IRI�:.�11SE� � VOM-1COURT
OWNER
CONTRACTORDESIGNER I ENGINEER
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-SAN it'r_'iiNA6t1NNO CA P11409
SAN HEKNA:}tL NO CA 42408
009)3181-,6007
USE OF PERMIT
41T)
i,&S 1I, t: SAA4H Iq,A TY.PK
1;689.00 SF
PQRCTWAT'10 W6.00 SV
4l6.00 SIS
IMTI,M. TED COST OP CONSk"SYjt.1CHON1
itf�+,t"t�i.l'� �' ii�1J �@1i�iNlyFq.kZY .
101.-000.439-31.8 $135.4+)
t;aNTJRU(34Tt0N FER 101-000-418-000 V46,51
..I..I;.CT1Z1C,A.L I:jlrl .. $ti.1-0t:)i° =47,0 -OW e16,94
l?[-.U3%4BW"_ F` KH 1.01-000.41.9.0)0 S148.00
S'rG,N0 .Mf,)TION Y!Y- , 91',810 1014** -241.-000 .. 510.13
011tirWING F.RIall 101,-000423MID $20.00
f€ 'R.A,S!V UC"UAf: SW 225400-44:1-342 S211U6.
AWC IFN 1aURLIC PLACES - REM `1014NXI 25 5-000
1
'1")TAI, C.'C�l�sISMA.iC�71CJR1 AND PLAN CHECKPAM
LM PRE -k ID FEES
40.Of1
J U L U 1 1997 TOTA PERMIT VEFS S.IfHtK NOW
53,396.46
GITY OF LAL 01NTAs-.
,'r,,,
RECEIPT.,
DATE ' t
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION 7T
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 Farts
OX to Wrap
Q
F.A.U.
Framing
d
Compressor
Insulation
d 9
Vents
Fireplace P.L.
Grills
Fire lace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
D /(
Drywall - Int. Lath
Q
Final
Final
I71 4ZZ,
POOLS - SPAS
BLOCKWALL
AP ROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP OVALS
Gas Test
Electric Final
Waste Line`s
/
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
Fixtures
'Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)