9612-072 (RPL)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
ProfesiRonals Code, and my License is in full force and effect.
License# Lic. Class Exp. Date
470-640 B_ e':� - 12JIU97
ate 1 `2 1-q (Signature of Contract on('r L
OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 orloffered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with licensed
contractors to c6nstruct the project (Sec. 7044, Business & Professiohals
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.
0, ( ) I have and will maintain workers' compensation insurance, as required by
,Section 3700 of the Labor Code, for'the performance of the work for �hic*h this
permit is issued. My workers' compensation insurance carrier & policy no.. are:
Carrier Policy No.
C !TX170.) C 0.'
(This section need not be completed if the permit valuation is for $100.0 0 or lessJ..
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�hose provisions.
Date: 4 Applicant— NI;A-Yo, A
Warning: Failure to secure Workers' Compensation coverage is j dawful and
'1�
0
shall subject an employer to criminal penalties and civil fines up to 1100,000, 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 clay'� 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.
Signature (Owner/Age
PERMIT# CONTROL#
BUILDING PERMIT 9612-072 4474
DATE VALUATION RACT
LOT T
JOB SITE
ADDRESS 78-V.5 DULtri, DEL At" . .
APN
I
OWNER
CONTRACTOR / DESIGNER / ENGINEER
IANIN.tf DEVC0 INC
I&IFERIAL SUN CO'Wf PLUTCYION
P.0 BOX 1723
T325 TARQLFIV. CANYON 9D 1.
PAIA11 SPRI[NGS CA 92261
PALM SPIONGS CA 921263-1
2277 ' 37P
(6) CBL -4 37
USE OF PERMIT
POOL ANIXOR. 841A.
ix -0 alld spis u4illy
PWL &WOR SPA. I's
AKSTJIMATU? 1) CYXIT OF COINISTR UCTION
12.000.00
PLAN CHECK ME 101-000-439-118 "t 7.75
'Mr NICAL)TE — POOL. 101- . 0-1,21-000
.90 -
IT,% —N.M. -101-000,4204M $41.4)0
PLON-IfiINU 1�'FTI K)CH, 401 -000 -4 -19 -ft)
4
SUR-TOT.A.1, CONSTRUM10N ANT) PIA, C14
DA L r; P"A"
a f—dD
34' Ae. ' f I t
S NAMM
S318.71
DEC 6 1996
C�AXSZ c)r= I—A -C
—N-11INTA-
%--*I 1PATe—. DATE FINALEP ]INSPECTOR
INSPECTION RECORD
OPERATION
I DATE —FINSPECTOR
OPERATION
T DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground. Ducts
Forms & Footings �f W
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof D k
ExhaustFans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
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 /7
Equipment Location
Underground Electric
Underground Plbg. Test e7
Final
Gas Piping ��z TX
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 . , . f (
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
44t
Final
Final
Utility Notice (Gas)
ELECTRIC L A
. JPP�pv LS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
E)deri6i Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Lltifity Notice (Perm)
COMMENTS: