9907-194 (SFD)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 # Llc. Class Exp. Date
6, 3% 722 3 2 B OVW20(
Date S gnature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the foll6wing 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 affirrii 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.
( oo,<ave 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 work6rs' compensation' insurance carrier & policy no. a�e:
Canier Policy No.
IVID'YAL %411-cjl, CO. G"t 1 A"X_ '15 9.4 3
(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 that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith. comply with those'
Date: ,e. 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 Applicatian 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. Ea�h 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 property for inspection purposes.
&:: .1-6-00
Signature (Owner/Agent) Date
PERMIT#
BUILDING PERMIT
990-1-194
DA7� VALUATION LOT TRACT
W $11[24,336.30 9-4 2860 1 -1
qAN 0 0 2001Y
N
JOB SITE
ADDRESS 79-660 USKRT WiLLMY ST.REET
APN
I 649-433fl,4620
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CATEIA,US HL[7.Sfl)EN11AL CON1111,4111NIMES,
INC CXrF%1,U.S_' MIDEHIIAI.. C0NI,%,A1JNrr. IES,
5 PAitK PLAZA, SUM 400
5 PARK SUTME 400
IRVINE CA 92614
MWNE CA 92614
.972
USE OF PERMIT
SiNGLE FAMiLY DWELLING
3XFV - Lc),r wt PLAN 3R 1113R"T CK)LIS NOT r140,kJVJw1 rJL0_-'K WAI.L Olt
f1(_A_A7S%44J_AJ4 CHEXX XODUCA-10N APPLIW FUK MULTIPL11-
11ZAC'r =43TIZIXTION SF
110RCHPi i�Tt 10
450.00 'SF
A; A. 16
P(,AW (7 ' F411�17K 'Ff;,T-., 1153 7,14
NfI---..r_'TJANXA1XPE '
ELEC116CA!, fr,-il
JILLfM1:3INQ1-'FS 101-000-419-000 S l61'MAP
101-000-423-000
ART irs! PUik.k, PJLA.k�011 - tcF.�;I.0 70i-000-255-000 S66,84
LA?%1hA.C41Wk
RI C0N9rR UrXIGN AND PI.AM C'Hf-('K
LESS TIP, E -!1.,\D_) fl.,ES
SIX10
RECEIPT
DATE
1D,7
/T _�7,
INSRM
N (.1
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE I
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-2
Underground Ducts
Forms & Footings
Ducts
�r � z r_9 2—
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
C
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
A2 Ye--.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
1-11 el
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I
Underground PIbg. Test
Final
I
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
- _210— 611
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) —24 -7—
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
Utility Notice (Perm)
COMMENTS:
Pm
T:six 1140<
CITY OF LA GUINTA w.
PI LUI xWr) /, - 11 �, - : 3 3 v
Q t: I U FA TME T k'�t
777-7012
MSPIECTION REQUEST LINE
M-7163
owrw CATILIVS RES. C NIMS INC,
contwor -CAl LLUS RESJ
pwwwt Nu"'Aw 9507-194
POST 6N—J-00-1-"N"-CON—Spld-u*"0u—t-o�L—Ael—
INSPECTOR MUST-11rati ALL APPQQLeLLE SPACES
Joe ADDRESS 79-660 DESERT WILLOW ST.
SIM o 0((:)T 83 N A PERMT DOES Nol,
�ZA
INCLUDE: RLOCK WAU OR POOL.
)UND P
NOT P(
.... ..... 11 ...............
a fir_
i wit NO WORK VNT11. 0 HAS Bh SIGNS 0-
DRYWALL INTMOR - ____wEgh—
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