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LICENSED CONTRACTOR DECLARATION
hhereby affirm under penalty of perjurythat I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals1 Code, and my License:is in full force and effect.
License # Lic. Class Exp. Date -
•Id"K12 B-1 . 12•/.11f 47
/''' ! .7
Date- '► ' `- Signature of Contractor `fir'
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.
S•fATF: PI_ItJ).) I_.Hx"vl'y/�-'►5
(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,
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 thoovisions. ,a
Date: ' �'' Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject.an employer to criminal penalties -and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this -application is made & each person at
whose request and for whose'benefit work is performed under or pursuant to
any permit issued as a result of,this appiicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit. issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I"have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forip purposes.
Signature (Owner/Agent)°'µ're- {' ' '" Date)
BUILDING PERMIT PERMIT# CONTROL#
5I1►91S-l37;� 3325
DATE 5115/96 VALUATION %1.. f'oo LOT TRACT
JOB SITE .I6 -44A DUNE PALMS B!e.![D
APN 649-040-014
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I:t,;INKIr;I;OMKIS.:I;C"I'1ONCC),
6400 IJUIvi� Pti.L1iS E4)
460:351 WLDEN ff.O L ,NES.
1.A QlJfNT'A (A 9'?1253
!JAJAW 0tt51r'. l* C,A 92700
fit;17-0- CB1.ff
USE OF PERMIT
t.a-'MAM. t3fJl A N43
FIRE, FORTHE", F01,1_0WINO - iNSTAiL .73 WIMsoW
IkFI"II,,/!C]iMFNT, I IART) WIIIItl? :.I) ANI7 A 0 D TO ALL 1;$ED) ZCKIN1S ANT.) CUNIT Al;1,Y,1-04:'KI'L'!)
I1AIA,WAY, RIA il.ItLD LIN►INGR(u)R4 .1 -IN ANI:+Rt'+�.)F 518IY YWC''ioD
lrA&LI►A'I'ION fit 1!!111►.+.iQ 1.11
±'117 6ii31�'1'ii;pA 4;<:AW'.ti' ()91' (t:)NS'1'HtI( '100
frt3�t3llOi.iNf
PERMIT IFI; , SlJt4'EIi ARV
t rasrltlx rlc,•� Ira- :0I -W)-418-000 8,2. do
NFEE:HMIC AL FEE i01-000-4211-000 S t.S.ilu
I f:i:C110 A3.. FEE 104 40)4 )(1-000
SLI IY3' AL (:t)'NSIMLK"-iiOIN A.ND FLA14 CHECK
$5112.00
I:XSS i'RI'?-PAID FEE'.,
$0.00
"IP A9., PIEAR4M FEES Y'�U ;`OW
$512.00 .
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I 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 Wali Insulation
Condensate Lines
Party Wall Firewall
"
Exterior Lath
Drywall - Int. Lath
Final
Final WPOOLS
BLOCKWAL P OVALS
- SPAS
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 rest
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
Final
Wily Notice (Gas)
4
ELECTRICAL APPROVALS
Temp. Power Pole -
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior'Receptacies
G.F.I. '
Smoke Detectors
Temp. Use.of Power'
Final .
Utility Notice (Penn)
COMMENTS: