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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
6906-15 H 613W98
Date , , �/v 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.
( P) 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.
a:tA: C F%T 1i�.tL 035-97-1230
(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, �s_.h.ra Vforthwith comply with those prov ions
ate: `^� d ,' Applicants -
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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Aignature (Owner/Agent) �� Date
BUILDING PERMIT PERMIT# � � CON+T
y�Ro`� f' ® 5Ax
.fifl LOT TRACT i
DATE (�J-�2710,58
V
Orf 9/98 VALUATION Sl79,914JOB
SITE
ADDRESS 30-275 DORAL ST.
APN 769-740-06
OWNER
CONTRACTOR / DESIGNER / ENGINEER
It M!I.(.A4FS LLC
tu1' 1:��,' °sS•S AIEta''f'S, INC.
P.O. PMX 8.10
1.12 .E. UA11VERSM DRIVE
LA QUIMA CA 92253
PHOENIX AZ $5034
0021257-1636 CI3LN. 4M
'
USE OF PERMIT
PLAN 16A - Sim < RIT 1101-AL—S @ LA QL%1`iA;F A1R A'VrS = 155?/. PLAN
CF1 CKRED tC'11014 AffIL1M- PLi
Ai
APR 0 91998
CCS-10illi CCl%fSTRUCT1.014 ?.Iso.t10 w
43ARA0&0ARJ)(_*T 0 8 Lia QUINTA
�CITY
4i: F Of:
rESTI i$A`Z ' D (M.3'T OF CONSTRUCTION 179,914.69
C;CYNS' 'RUC'i'TON FES 101-OW4 k8-000 $919.50
-9-1, AN T1FCX r176 10 i _000_439-3 18
,LECariA�ilCAi ;M ..1 o i,miDWI -00 :pct
LUCTR CALFFA SW3.04
PUl'iNIIH1NO.FIR".. ' 101 -CW -419-000 $156.50
'MONQ NK)Tr)N FEE. R—EbB..) 101.-000-241-000 117.99
t' RAl: ING, I.O.!-{IOf3��12'3 000 �Q.Oo
1NF1ttagTR(Jc``7"t WF -EE 225-000-443-312. 54,44.74
AW IN PUMJC PLACES . REST •701-000-2§5-000 $199:79
SUMMAL CO- NSTRUMION AIND PLAN CHECK
LESS PRETA�I F11E
. M, �,14akZMI 1 2i�R V-8 01J �N0 -V� -
-s��'M.f
TOT
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 4_ �c /
Slab Grade L �<
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap dl r
Framing �I
F.A.U.
Compressor
Insulation
Fireplace P.L. l
Vents
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines �� ��j
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
ginal
Utility Notice (Perm)
COMMENTS: