9706-015 (PLBG)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 # 1 ,� '7 Lic. Class Exp. Date
,f/
ion l Y!a/,
...V ate Signature of Contractort
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.
( ) 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 employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree thatjf I should become
subject to the workers' compensation provisions of Sktion. 3766 of the•JLabor
Code, I shall forthwith comply with those provisions
Zate: 4% %4Applicant—.`•/f1`��'�1• f `
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. : V
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 t
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 per issued as a result of this applicatioAbecomes 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. /
r * f
Signature (Owner/Agent) �' r 7� 3 �- Datef
V
w..
BUILDING PERMIT
PERMIT# .
CONTROL#
70"1
5267
VALUATION �iyZ�1 0t% LOT
DATE a97
TRACT
JOB SITE
ADDRESS X700 i'tA"P,Ni t)A NM R:*CCRA
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
' ROBERT a l�i':f,,.i:ii.l�al l�,
r
HORSON +...6✓✓NIST RILS:.. iTION
53 -IN A1,EKIDA.1 ERRERA
71266 CYPRESS LN
LA QTANTA. CA. i 12,"
IONCHO J1t1'1t.f'+GE CA
9.2270 '
(70)328.4080. COU
USE OF PERMIT
ilst"`1..1 EILSA,�t)i�f iAitsly t", af,%"A Ek �,'ONMICT
VALUATION N
1,20 . A iT ;i
�te'.�ri9r a'II �9 4.�d .!4
t`>ON TIR`ili TION
1��vZ#i.1Z(D
.�iit
P0,JnafH NGf FIX `;EWY;.R 401-000-419.000 $31►.eV
a � ,
1 : ,: CONSTRUCTION AND PLAN CF1J_�= K
530.00
varCYI'�AT,
LEI &S
MW
JUN 0.4 1997 TM At, Pi+,RA9_-4 FEEN DEf'E"N(DW
�Jfl�iiA
Clip LAAQ�1I�iT�j
RECEIPT
DATE
ey
DATE FINALED.
INSP TOR
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.lnsulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
I
Final
Final
POOLS - SPAS .. .
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg.-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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
-Temp. Use of Power
Final
t.Utility Notice (Perm)
19 63238
Received Fromm v '
`-/
A
Address: 2 C, LC
'
AccountNo. ���
? Loycs) (�►-� is
Service Address �_� %CLr�r
�[//e!'ne of
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Laterals)
❑ Detector Check(s)
❑ Meter Surcharge
l;YSanitationCapacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
k 24 Tract
G.A. Code
IN
Q . f TOTAL $ i
Remarks: rk k ` 4-��zz)�a nw l 0 w� koL T '�^ �.. r/,�� 7t < r 1 r^ '
&C6py to: 1
/�n'
Cash `. n.l E� L..
l` �� Z (�.2 2 Water Service
Check
Money Cashier
Order CVW D-438 (1 t les)