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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty.of perjury that I am licensed under provisions of
Chapter 9 (Qommencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class ' ExprDate
i
3?i,3iSf1 � ! ,�c�'31lf'iJ
•abate �' "''� u �f Signature of Contractor
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OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1 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.
( 1 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.
Cll 111 w i t aii;Y✓y a ,+�1�
l: �tj� `..l�AY,I�' Ua r i n.1M'a+.u�w
(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' compensatipn provisions of Secf'on 3700 of the Labor
Code, I shall forthwith comply with Thos` pf? lq .n ,n
,6ate: moo... 5. Applicant, �Ir-T
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 Lthe 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 pursuantto
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, nd.State�laws relating to the building
construction, and hereby authorize rppresentatives%of this City to enter upon
the above-mentioned property for inspection pu osq's.
ySignature (Owner/Ag(erit) "• •� � �- _ '�n '— A•-; � �'% Date,
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT �'TRACT 7 513
81120/913
11)
JOB SITE APN
ADDRESS 0.99.1 EISIr Nfld.OWCM D-r't1.V6,",
OWNER .CONTRACTOR / DESIGNER / ENGINEER
THE S..OSk�. C't�V� A;i:ti, f A V 1�11AI'D1 K M)Id�'.
PO iS+; X 127 10 :11-903 81:: tiR.;. i- ALK, SUITET
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:PAL±4.1 D1 SEIt.T' C Yk 5P55 PALMI DE,SEE(;.' CA 19?;M
(760337-9484
USE OFPERMIT
D1:J1iC+x.ITK)N PIRI )R TO REE 1,' 4:*jDN. a',_ FV1)I31T1(__)N TCS 61JAR1J
WAISF, 1'NUANCP' CV L ilitJ.f'1�'It'�41i' tif3't�1_L WYI: GUARK Vt * FE BAUD .9t,WtSl QLJRNT ISSUA74CF, OFBIAL ,C Midi Pt�f�f1 IT
AUG 2 0 1998
ATY 4F LA QUIN�
E'.1•Y..Wd'�TEM COS4 Coll
X''13:UMIT FEX SUMMARY
tat N101,1'1'.K N t fg3 014*0-42 3-W)
til i1 -Q{3 t .1, C't�NtiT'i't;C"'t
ION AND P1,ANI +."HEi(,1_id'i ()ii
LESS 14110,00
TOTAL iI'FRINtfT h+d':CS WRe, NOW I $.14ii fJ
BY I DATE FINALED - I INSPECTOR
MSPI CTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULUNG APPROVALS
MECHANa CAL APPROVALS
S. -t Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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 - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PL 4.DM [ WlS APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Seaver Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTMCAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F. 1.
Smoke Detectors
Temp. Use of Power
r
Final
Utility Notice (Perm)
COMMENTS: