9611-068 (RPL)Cf)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensecl�lncler provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business,'arld
Professionals Code, and my License is in full force and effect.
License # Lic-Class Exp. Date
6_90773 C�-_53 C-27
b at gnature of Contractor J
/a e
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 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 conse nt to self -insure for wo.rkers'
compensation, as provided for by Section 3700 of the Labor Code, for -the
performance of the work for which this permit is issued.
(J) I have and will maintain workers' compensation insurance, as required by
Sdction 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' conipensation insurance carrier & policy -no. are:
Carrier Policy No.
STAT&FUND 1061437
(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 issu6d,
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,S6ction 3700 of. the Labor
ode, I sh 11 forth;vith comply with those provisions.
VDate: p p I i c a n t
to
Warnin Failure to secure Worzeirs�totmr�e%a'ti� �covwerdgi;eEis unlawful�ancl
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'rnacle to the Director of Building and Safety
for a permit subject to the conditions -and -restrictions set ioi�th 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 propeTty—for-inspection purpose�sj
ent Date
VSignature (Owner/A.*1,_--
PERMIT# CONTROL#
BUILDING PERMIT 9611-o" 4354
bATE 1.1/21./96 VALUATION $13,00%00 LOT TRACT
JOB SITE
ADDRESS 50-445GRANDIrRAVEMSE,
OWNER
CONTRACTOR DESIGNER ENGINEER
A'YkES GROUP
DIVA"10-7 If"A"I'ME N171"I.M1111SES
355 BRISADI. 9f. -HA
28-070 AVE. 11R11MAVMA
CCMANKRA CA 92626
CWTHEDRAL CITY CA 9223-1;
CaLff 1888
USE OF PERMIT
PO(X, ANDOA SPA
POOL MD SPAONLY.
POOL KINWOR, VA 13,00D.00LS
31 %VTIRD COST OF CONSTRUCIIIIIN
X M
131000.00
PERAITt FCC NUMMARV
. CUECK FEE 1014W-439 18
PLAN -3, 393.60
ClaKSTRUICITION, mkul- 101-000-4184)(110 $1441.11`10
MECHANICAL F% - POOL 101 -WO -421-M $24,00
PLUNWING FER1 — pix)L 101-000-419-000 S27.00
'SURIMAI, XOMTM.. 'fir�n.'ILINANf.)PI,ANCI,-f*6(.".'�r
18111160
LESS fif',E-PAMHES
$0.00
NOV 2 6,1996'
V
-RE-
D L D
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I 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 Fir6wall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
,.§et Backs
Electric Bond
.,00tings
Main Drain
Oond Beam
Approval to Cover
Equipment Location
Underground Electric
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 1�77- 1�
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiriog
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)