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LICENSED CONTRACTOR DECLARATION
:Ii heret?y affirm under penalty of perjury that I am licensed under provisions of
Cli %t 9"(gammonlcing with Section 7000) of Division 3'of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date '
Date Signature of Contractor
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
I am exempt under Section B&P.C. for this reason
Date a.. ?../.rSignature of Owner. ...••^ i'.r""""'
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 that if I should Become
subject to the workers' compensation provisions'of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
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 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 4his 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.
re (Owner/Agent) - . / '"Date Ze.N —22 -''r(0
PERMIT# CONTROL# - .
BUILDING PERMIT !WMAM7 .42,62
DATE 10/29%" VALUATION g1��if.(o LOT TRACT
JOB SITE
ADDRESS SU -145 1111SEN:HOWER DR.
APN R
770.7&�3.��
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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10S; i~c Y9A11YN, CAN011.
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35145 WSENHOWER DR
f.A,Q?,iIMA CA 92253
USE OF PERMIT
WX S'ALL NEW f% ANtJF ACfUR 'l) Y, f11ET-14A IR
't%Hfa1'fti'iiJili � 4t�l.iliy L:�
P1 'AN CwEiZ9. i, ilk: $9.'11.5
r-�,Zfft`t`t2++aCl�S�jtl!F� 1i11.d)�3�A;l��t�ti0 $t�.titi
rp,;, .fi.ta:�i(, ^;101.• iioi z11-000 $.50
V
Q+ : 1's'+a�1.. t:' _ STP:U'11014 AND PLAN C IL LICK
LESS PRE -PAID F.F'11113
$0.010
OCT 3 0 1996: 11%.Ithirl' FE GN 0VV,N0W
$25.25
6y
RECEIPT
DATE
BY'.
DATE FINALED
INSPECTOR
JJ
INSPECTION RECORD
OPERATION
w
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
i BUILDING APPROVALS
MECHANICAL APPROVALS
' SV Backs
Underground Ducts
Forms & Footings
Ducts
Sl! -;b Grade
Return Air
Stael
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 Wali Firewall
-
Exterior Lath
Drywall - Int. Lath
Final
Final
-POOLS-SPAS
BLOCKWALL APPROVALS
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
1G.F.I. �,
Smoke Detectors
ijimp.' Use of Power
Final
Utility Notice (Perm)
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UTY OF LA 'i
BUILDING
COMfTIMt'ILLY
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CITY OF LAANTA
BUILDING & SAFETY DEPARTMENTCONOWTIONALLY
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ACCEPTED FORMNORUCTION
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AND ALL APPUCAELE CODES
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CITY OF LAANTA
BUILDING & SAFETY DEPARTMENTCONOWTIONALLY
;
ACCEPTED FORMNORUCTION
SUB9ECT T® IWALATI®N AS PER
AND ALL APPUCAELE CODES
DATE ,p
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