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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
I
Sdr1 34 12;31N
Date I Signature of Contractor J -
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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.
(V[) 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 emply any person in any manner so as to become subject to the
workers' compensation laws of Cali rinia, andlagree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Gode lls6ll for{hwith'comply with those provisions.
VDate: � /-Applicant
t
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
t"application.
.t 1. Each person upon whose behalf this application is made & each person at
Iwhose 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. f i
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ignature (Owner/Agent) %' 1r t - Date / �� /fJ
BUILDINGPERMIT PERMIT# CONTROL71
DATE VALUATION e� p LOT TRACT
4 j 67.3
JOB SITE ADDRESS 43-916 GENOA UPJ UaZi� t+"
APN .
OWNER CONTRACTOR / DESIGNER / ENGINEER
111
.1333: 18613 NAT'US DRIVE
PAIAM DESS;; "T' CA 92254 LA fttlfhfIA CA 92',53
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USE OF PERMIT
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JAN 211998
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CONSTRUCTION Fs 1431-I)f3t)�d3ii-lit3o .9. 50
3=IorfCKC1Kr.rf? !04-4)(343-,1tel_33S
fv1iF,,t-HANIRZlL F'iEk: $53.50
ELFC31t1:t=AL 19MI .1O -000-420-M $12%3>4ti
PLi3M I"INi; FE PH 10.1-0001419-01[y) 3140,75
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RECEIPT
DATE
By '
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Forms & Footings
Slab Grade
_
Steel
Roof Deck
J.
.3 - / ?- 8 =df
O.K. to Wrap
Framing
Q
Insulation��—
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
¢ - 2 �-
Drywall - Int. Lath
Final
_ /o-
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
ELECTRICAL APPROVALS
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Final
Utility Notice (Gas)%�o
/Q _i
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
E
t -
Final
Utility Notice (Perm)
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Final
COMMENTS:
POOLS - SPAS
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