9803-022 (BLDG)U)
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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 effec
License # Lic. Class Exg.aoat&
I
Date Signature of Contractor R•–r''
OWN ER-BUILDEFGDECLARATION
I hereby affirm under penalty of perjury that I arri 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.
Z ) 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.
SITA'I 1 FfJti1:) 120741;. *
(This section need not be completed if the permit valuation is for $100.00 or less).
O (,certify that in the performanceofthe 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 aVedt if I should become
su/bject to a workers' compensation pro?'SOh- S on 3700 f1the Labor
CodejJ s fq tl;iy ith comply with these r visiog
WaOfjng' ailure to secure Workers' Corilpen'sation coverage is unlawful and
shall subj ct 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 ubject permit to cancellation.
I certify that I have read this application and st to that the above information is
correct. I agree to comply With I City, an ate laws relating to the building
construction, and hereby auth • rlriz� re • resa tatives of this City to ente up • n ,
the above-mentioned pro ert for ins e do purposes.
ignature (Owner/Age 1 ! Date
BUILDINGPERMIT PERMIT# CONTROL#
6 919
DATE yf� i VALUATION �,•#� LOT TRACT
ADDRESS 52-29.5l�.VENWA���?,�.RE'W` JOB SITE
APN 773-263-015
OWNER CONTRACTOR / DESIGNER / ENGINEER
i ALPFI S J'ON'ES ROGF TTLi, SPECIAI F Y
2920 JUNIPER AVE 74(173 .AST',L,;R .DR
MOii.i 0 BAY Cttt 93442 PALM WiS.ls.M, CA W211
(760)341-6073 CBLff 14'hU
USE'OF PERMIT
BUILDING
Rci-.=i2,OOT - I-NIMTIGA`t'iO `FU Cor $30 FOR VJL` RK S C VU "Will -%"}U T
FERN 1T P! R 1994 UAC SEC TION 304.5.
IBEZ001-
5,lti�,tjii
T'lt.��:'�i'�'�.F�i1�:� vi0$� ci�•��5�'�S;'X�J�G"�'�OP+ do�u:i.�i�ii
I'Mirf FEE SUMMARY
REROOi' FhV SX00
— Fl+ S'i di # sal CCJ1t+i S .E? 1Qi;-Q€1Q-423-QQ(1 540,00
O
MAR 5 1998.
CITY OF LA QUINTA
LESS T1RE'--P;UDF2148r
TOTAL -.PERMIT FEE -4 000 NOW' 3(113.0€3
RECEIPT I DATE I BY
..1 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
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 - 1 •. La
Final
_
Final ,3_ _
POOLS - SPAS
BLOCKWALL APPROVAL9
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
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
t
Final
19tility Notice (Perm)