9801-090 (DEMO)�., 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 # Lia Class Exp. Date
171 6 ;9 ii r 1sl
Date � �. � � 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, a5 6Wher 6f thi8 p'r60erty, 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:
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.shouldbecome
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
JDate: f _ r. �1 Applicant {� -
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. '
/.Signature (Owner/'Agent) J Date r- >
PERMIT#' CONTROL# ,
- BUILDING PERMIT.'
DATEt�f4� VALUATION •��� LOT Y .. TRACT '6722'. % tai _ .
r L
JOB SITE
ADDRESS 43,976 WA8;3i1: #t` CTIR,.iN STR..
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
i..n �^i • 'i1'i ,}'�' 1``/i Y f I E V' A.'i11Y,
G.aur�4it.e...���.,,<
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PALM J)E-SETIVII CA 92260
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USE OF PERMIT
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JAN .2 0 1998.
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RECEIPT
DATE
1,13y,
DATE FINALED
INSPECTOR
,
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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
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 APP ROVA S
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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
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
l
Final
Utility Notice (Perm)
Vl/iV/OV L'Y•NV FAA V4V4JOV441 LiTT AAV VV.L
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Alliance Environmental 15705 Arrow Hwy Suitc 0 5 r.
1�
Grow. Inc. Irwindale, CA 91706
FAX-
Number of pages including corer sheet: ..
To: from
1. Yr
Arc elr
I Phone: Phone: (626)338-1389
-Fax Phone. Fay phone: .L26 338 -7 . 4
'"•16-1998 1+31PM
FROM .1—M' CpNTRAACTING/ALCG 714 367 eS16 '
P. 1
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- Page:
Bulk Sample Analysis Report
Client Lindsey Monsen
Report Number.
Report Date:
35232
1H3l88
P
P.O. BOX 6581
San Bernardino, CA 92412
Oabe �ivod:
1H4t98
Atter: .teff Bs11it
Projeft Mea Foundation, Ina -43576 UlashinVfvSl.
Job Number:. AZC804t3604
WLom a bulk Asbestus sample is m=ivt& sev&a1 wive paw of -16e sw*ic ase: ia'm•Rd ami pIt a tallad paai.sisb MW sample
using fogs. Tb= X61 �b'm &= V1 on amigo
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usft PI K tbe priciples of Pabrind light and Mievsarpy and dapasion t osing NIOSH 7403 memod Ihis moffind is deiinsd
In &o EPA 6WM4-=-=0. 'L MAM McPoa PpriM
4f Ash +c to SaLc mtu]a9oe►Swmplas ' Afsar {)bet ismwiGlaon
by p +
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.
Sample Dateis
'Noe A•0esloe
� 1
and J&H Lab Sample Lxwafion and
IID No. Malaria{ s+t dic+t
X .rye
Type
°!.
Damaged Area
None Detected 6ynviaaae Fib -
O_012041
Non -Fib. Mat
'
01 -2041Acovs>ic
2 Damaged Area
None Deteted
01-2.042 Acoustic
room -Mb. Mat
3 Damaged Area
None Detedad Syntftettc Fri,.
�5
of -2043 Acoustic
Nort+b.Mat
85
4. Damaged Area
None Detected Sync Fib.
4
01-20" Drywall Mud
Mati
$ Damaged Area
None Det:mied Syntl ebc M.
4
96
01-2045 Drywall Mud
Non -Fib. Mat
6 Damaged Area
None Detected SyMhesc Fib.
4
01-2046 pryMrall Mud
Non -Fib. Mat .
.
(hrAA Q dk AatteAos Ptetider►q AnatflicW Tam Proararn Lab Nw. i i a71) • .Lada eontfadft.1Lr_ J Asbestos sad lead Cartind Group