9706-142 (RPL)F1
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
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).
O 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 re so
Date `E Signature of Ower
� !
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).
'X} 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 lawsidf'California, and agree that if I should become
subject to the workers' compen on provisions f Section 3700 of the Labor
Code I shall forthwith comply with those rovision .
Date "i 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 onr 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
ic�onstruction, and hereby authorize representatives of this City to enter upon
�fhe above-mentioned property,for inspecti �rposes
�
Signature (OwnedA�ent) . DaW �+
BUILDINGPERMIT PERMIT# CONTROL#
4706-1 12 5420
DATE VALUATION LOT TRACT
fi/27/`7 59.';{73.20
JOB SITE e�
ADDRESS 5141 AVW-,tNWA balAiRACRA
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
52810 AVLx IDA, FiCvRRERA
LA QU1NTA, CA 92253
USE OF PERMIT
M'(JC311
POOL ANO PLU:3 6s L.F., 5' t,3J1id(.. EN 'ttiiA L. O L Y STANDARD.
POOL r`+AiC: OR SPA 7,�if,l()0 LS
5 ( 1'. WALL 68.00 LF
fi x09'' OF CONti�UUCT ON'
91372,20'
€ LAld C116CKF1339 101.-000-439-31.8 $frl.'4S
MoQ9A4rJXr,AT. tali; -E'.. PtX*X, 101 -W -421-000 5:A rxi
17
1';:1,rt;11'.1C,d1.L VI •. i'C�(ti•. I (31-�ICfl-121 i�(! � 13.t1t3
$27,00
r:C1N5>:�4 �1E "'i 1�?.f�t.i�faki 1014,,)-418-000 $'117,00
a5
PAI C1:!'1 A1.INS'IIJt" CION ANT) PLAN
X27; 3t
LESS :1?ii.&1 AID t%.1aRS
10.00
JUN 2 7 1997
TOTAL 11 ERMT11' FEi�:�S01W N0, W
5277.35
OF UINTA
RECEIPT
DATE ¢
BY�
DATE FINALED
INSPECTOR
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
OX 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 L
POOLS - SPAS
BLOCKWALL AP)P50VALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test WE
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
Final
Utilily;Notice (Perm)
YI CITY OF LA QUINTA
SUB -LIST
.V1.
)WN
ADDRESS
JOB ADDRESS
19
1111.7 I%F1I II ON soil YQ MWO LQV s/11 LI IQ ,\/Y �1lll •11� YYIIVIIIa IIIV Id V YVII VYIY Y YI■ 1■ Y VVIIvvIVY VYV 0z1YVV.
t is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that
ire on this list are the same persons performing the work. Any changes to this list must be approved the
:ity of La Quinta Department of Building & Safety Dligt to work being performed by a changed sub-
,ontractor. Failure to comply -will result in a stoppage of work and/or the voidance of building permit.
CITY
SUH-COITRACT01't'S ;
TYPE OF
STATE
1lf/ORIfER'S .
BUSINESS
.TRADE
NAME
LICENSEONTRaCTOR'S
COMP: NAME/
LICENSE
CICENSf
NUMBER ON FILE :.
NUMBER/ '
..:
N......
EXP DATE'
WN
EXCAVATE ...::->;:>,:<:
X.T
PIPELINES:;`, _;.
C-34
a fu ua a 97
t _&t(o 1 2-Q 4
t$ti '`•
C-8
FOUNDATIONS >::::
ASPHALT.:;:::.::.,:::
A
FRAMING ':
�A�
B
STEEL/
1
C-51
7 31
STRUCTURAL:::..:.,::;
_
' :�:�` ��
C - j' •3
S)
MASONRY::
C-29
Zcc3�
3i 7
PLUMBING:>€''>:`:>'
C-36
LATHING : r : <'' : ;
C-26
C-9
PLASTERING.:11',"
C-36
HVAC
C-20
ELECTRICAL.:.::>".
y
C-10
(Generap:
ROOFING::
C-39
SHEET METAL.....,
C-43
FLOORING:'.:`'-` ':..
C-15
1
GLASS/ ,::...:>:.: :.:..':
C-17
GLAZING'.::.. , •
INSULATION: <
C-2
SEWAGE DISP:.. '
C-42
PAINTING/".', .
C-33
DECORATING:I...'..
TILE.
C-54
CABINETS/
C-6
INSTALLATION
FENCING
C-13
LANDSCAPING
C-27
POOLS
C-53
OTHER
4 TA.5
•
c!{' t�/3c �i7
state Fu13D
� 9 y�
L' ;ITY OF LA QUINTA
BUILDING & SAFETY DEPARTMENT
CONDITIONINI-LY
ACCEPTED FOR t' -`:--',"--., :-
SUBJECT TO INS -fAu.:'.-A"':a
AND ALL APPLICABLE CODES
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