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LICENSED CONTRACTOR DECLARATION
I hereby -affirm 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 # - Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm 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 (gm. 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 `t, , B&P.C.' for this reason
Pate 111-s,NA .0 Signature of Owner ' ��-,- ► ', ���.� `t . "' �.-i
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.
(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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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.
SignaIire' (Owner/Agent)
F
A"'
BUILDING
PERMIT
PERMIT*
DATE IQ/20195
VALUATION .1"ou.15j}("
TRACT
PT
JOB SITE ADDRESS
S3-5� 0 EISENHOWER
APN
774 -2224122 -
OWNER
CONTRACTOR
OV4'NERMIJILDER WITH SUBLIST
DEM41S N1 & SUSAN FOST'ER
53.560 EISENHOWER
L.A QUINT A CA 92253
cBf,.#€
(
DESIGNER/ENGINEER
J
USE OF PERMIT71.Ciii��CiUi �.Y�ivt)3 CrJF�:T3iI1r4TIU:
FEE DESCRIPTION
FEES
VALiiATIO-1i 4.050.04 L
ESTIMATED COST OF COINSI Ti1JCf I N
4r0,M.00
3'F,9tlVdIT. !<<'CF; NU.IM, X4..ARV
ISI, ANT CIEKX F3313 101-W0-439 318 �4b.SO
CONS' P.Llf- IC)M.FJ::�s'. 10f -M-a 15.000 $73.90
fi,F.C'I''LiCA%F"ra 1.01-ti(3()-42(3.000. i $15.01
STONG NUX-11 FEE - RFS L7 IIS -M -2414W $SO
1OCT 2 0 1995
13Y
Stili-?'C:?'TAL CONSTR'JCT'(ON AND PIAN CHECK
$134.30
LESS .PRE.4)A1D FE S
$0.00
TOTAL f'E13.i1 IT b EFS DUE rtOW
$:1:94.30
TGTAL nOncr v�,Rurr imi;fi
134.30
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 X
F.A.U.
Framing S
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 70003—
pFinal
Final
Final /
BLOCKWALL APPROV S
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground P(bg. 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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 6
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Contractor
JL '1 Y V2' LH %-PlJ 11V•1'H
Address
Owndsr,,Jrl i S �? SUS A,.1 FSS j62- Job Address 5356,0 E✓ &411ad6t L)#t•
This form shall be posted on the job with the Building Inspection Card at all times it
conspicuous place. It is the responsibility of the General Contractor or the Owner/Buil)
to monitor the sub -contractors that are on this list are the same persons performing
work. Any changes of this list must be approved by the City of La Quinta Department
Building and Safety prior to work being performed by a changed sub -contractor. Failure
comply will result in a stoppage of work and/or the voidance of building permit.
TRADE
SUB -CONTRACTOR NAME
CONTRACTOR'S
LICENSE NO.
WORKMAN COMP.
NO. ON FILE
CITY BUSINESS
LICENSE NO.
GRADE/
EXCAVATE
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PIPELINES
A41A
CEMENT/
FOUNDATIONS
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CEMENT/WALKS
6 DRIVES
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ASPHALT
d 1
FRAMING
rt /la
STEEL/
STRUCTURAL
pi
MASONRY
PLUMBING
r U7 EI Oxe—'T �I [-LtmB U
(6-7%/
LATHING
DRYWALL
Vqt c_C—_y S/I,' DS
� r 2$� s
G/
✓
PLASTERING
K//?
HVAC
141A
ELECTRICAL
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346885
ROOFING
N /A
SHEET METAL
FLOORS
gy . d U/,j �2-
GLASS/
GLAZING
N /�
INSULATION
SEWAGE DISP-
oq h9
PAINTING/
DECORATING
TILE
CABINETS/
INSTALLATION
�y dit)rrG2
ORNAMENTAL
METAL
FENCES/
BLOCK WALLS
1-41,4
LANDSCAPING
N�/a
OTHERS
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