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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of \ \ BUILDING,' �PERMIT
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and \ �rri3l . 4.4ij
DATE VALUATION LOT
Professionals Code, and my License is in full force and effect.
License# L•ic. Class Exp. Date .i
rldtr lU/,i�/f1 JOB SITE 741'i�1l1+.�1..Ki �1Urli4r/l1/t
r 1 / ADDRESS
Date," A �4' Signature of Contractor
OWNER -BUILDER DECLARATION
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). t.
( ) 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 ofAhe following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 eof 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 isissLed..My.workers' compensation insurance carrier &,policy no. are:
Carrier 6SASI CARIN:9t.!XAll-sl: Policy No. " � .5
(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
Code, I shall forthwith comply with those prov Ions.,.,!
/ Date: 2. it w e f Applicant ;2 J, ..+. ,
Warning: Failure to secure Workers' Compensation coverage 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.
PERM51 03.04 r
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APN
CONTRA/OL # //�
TRAC 9Z5� 2 V 32.
OWNER CONTRACTOR / DESIGNER / ENGINEER
;:.E-NI..'C'RY CROWELL COMMIUNVIIE! [;c111r1'Jr4Y C ROV-1131. L coni ; UNl'TIES
1333 Sia. "..U• a;TR I V,1arlt, 0200 1333 SG. "a, rr, -E. 4200
SAN 8ERNAR IN, CA. 9408 SAN BERNA.liJ INO CA. 92409
( t09).V_ 1 -*007 X909 �f31.-GOOy MN 2120
USE OF PERMIT
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PLAN 7ND
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BENJAMIN AGIR AR. & ASSOCIA1
54159 PAIS,8,I&R.0 AVE.
1,433,00 V
85.00 ST
4X00 4
UST 14'1,A ED COSTOF cONSTRvU10-N
PER.M]IT h'FIE StJMMARY
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101-000.418-000
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101-000-421-0)
$33.50
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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 relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
/ � RECEIPT
Signature (Owner/Agentj/s;Zr-..+d�/ /— DatpJ;+ /C/—,;�
SUP,40.rAlk 1, CON 'SIMUX130IN AND PLAN 01ECK
1J.ESS PR13-f��UD iaEIS
"f'U.TA1,1'Eh'IRl.FT FEES IRT, NOW
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87,174.40
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PECTOR
DATE BY DATE FINALED INS
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.
OX to Wrap F.A.U.
Framing L( Compressor
InsulationVents
'
Fireplace P.L. Grills
z
Fireplace T.O. Fans & Controls
Party Wail Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall- Int. Lath
�I•
i Final
Final POOLS - SPAS
BLOCKWALL PPROVALS
Steel
_
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final Gas Piping
PLUMBING APR VALS 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 4& Encapsulation
,
Gas Piping
Gas Test
Appliances
Final
COMMENTS:. ....
Final
Utility Notice(Gas) 4P*
ELECTRICAL APPROVALS
Temp. Power Pole ,
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
1
G.F.I.
a l
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)