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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 alhd effect.
License # Lic. Class Exp. Date
/7
Date Signature of Contractor—AZ
OWNER -BUILDER DECLARATION
I 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 -or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, 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 ik- 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 formorkers!
compensation, as provided for by Section 3700 of t ' he Labor Code,,for the
performance of the work for which this permit is issued. :. I I
( ) lhaveandwill maintain workers' compensation insurance, as required by
S'Ktion 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:$1 00.00 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 370O.of the, Labor
Code, I shall forthwith comply with thos%,provisions.
Date: 2- Applicant._-�,;'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to'$1 00,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Ap�lication is hereby made'to the Director of Building and.Safe'ty
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 appli6ton agrees to, & shall, indemnify
& hold harmlbss the City of La Qui;ta, its officers, agents and employees.
2. Any permit is�ued as a result of this application becomes null and Yoid'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 h6reby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) -Z `4-W'1111 Date !j -
PERMIT# - ' CONTROL#
BUILDING PERMIT
960-076 3746
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 49-98106V,941 "LLE ESTRELLA
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
S AN" r, P, R 0 SA. C � 0 V EAHA. 0'. A�
WEMERN PACTIFIC "R100FING
50-407 CALLE 0ANALA
W2 LA CAMPANA VAY
V
JA QUUWA. CA 9ZI53
PALM SPRINGS CA 92260
C.MW
USE OF PERMIT
02WERAL BUILDING
TUL�ROOFIPO. LYUR17134ANL FOAM
VALUAT-ON
EST tMAWD C0.51"OF CON.STRUM [ON
PERMITFIKE, SUNMARV
SUD,TCYCAL CONWRUCriON MD PLAN CIMCK
M-00
LESS PRE-111AID PRES
IS 0. 0 0
rAL PICRAUT -FE kS"OUEWOW
$30,im
JUL 2 3 1996
Z By
RECEIPT
1BY
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
SetBacks
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K to Wrap
F.A.U.
Framin§
Compressor
Insulation
Vents
Firepla P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL'APPROV LS
Steel
POOLS -SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground El ric
Underground Plbg. 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
UU14 Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior* Re;cieptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: