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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 Businessand
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
574127 A l7
Date n 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).
( ) 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 M' add Maskers' compensation insurance car Fermi&•glicy no. are:
Carrier - Policy No.
(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' compensatioJ�I-provisions of Se do 3700 of the*Labor
Code, 1 shall fo with comply with fiose provision?;'
Date: r 1� Applicant ..'`t I
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:
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
CWnstruction, and hereby authorize representatives of this City to enter upon
tile abova`.Mentioned property'for inspection purposes:'
Signature (Owner/Agent) *{s��%<�+ Date���✓�•z
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BUILDING. PERMIT PERMIT# °°NTR°`#
�.. ->�.» 3 5 6 7
DATE . VALUATION' LOT TRACT
U20% si's,000.m) LQ CA
JOB SITE APN
ADDRESS 79-355 DESEIEt'!i t'V[t D
OWNER CONTRACTOR / DESIGNER / ENGINEER
C.61NIT. Ply HOMES
1 S3S'S.1) �1, 71 t..I§
SAN 13f i ND(NO
USE OF PERMIT
P(Y)1,. A.'0?*A.0N1'Y
S'li?4'i N3OI�SOA� C(�1�18"1`RiSC" Iia 01�
68805A 13EM2 RD. IIE9
CA, 92409. CATHEDRAL CITY CA 92234
t;G10 3?.4 iw32 C8LA 1044
f'ooli,. RN:tfGg1 SPA -
15,000.00 LS
Z`.S'I'.i1N9dA rx D COWFOF CON Ni`C.1t,3 CCIOloi 15,000.00
P.ERM4FEE SdINIMARY -
1, AN C1a13%"6: F14, 7 I'611 -000-41V-318
410 i,3t7
CONa:€RLrCTION:FEW 101 -()00.418 -AW $1t;2.flfi
rVIW-I4.1vo a1"Ek--f-ou 101-000421-000 SUM
01-Y711RI;C AL F61i -- tufa 101-0004204)0 W5.00
1?Lt:.rNltalff,ICeFEL, �'-POOL, 4(11 -10W -49 -mo $27,00
' SGrB,TO'7.11.; CON.31'I3UMON .AND PLAN UTECK $3163.30
` GESS PU-PAD FEES 50.00
T01'.0, PERMIT FEES DUENOW
JUN 2 A • 1996
RECEIPTS DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTCoR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts 'k
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond 111,
Footings
Main Drain A' 410
Bond Beam
Approval to Cover
Equipment Location
Underground Electric ZIP
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: