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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 # Lic. Class Exp. Date
Date� SI r�ture of Contractor
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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 -
I1,' •'rebybaffirm 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 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 aujhorize`repfesentatives of this City to enter upon
the above-mentioned property fo�inspef ooln purposes.
�. * ,,
Signatu,.e tOWnr3r/Aaentl uDate
BUILDING PERMIT PERMITN CONTROL#
960",853339
DATE VALUATION $21N1.00 LOT. TRACT
JOB SITE 78-120 CALLS ESl�t��ii.3
APN
ADDRESS
.SL�-�e . lot
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CrERRY .1,10GitUr('rSC�'`'fp
ONVINER BUILDER
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78420 CALLE..1:•r7 i AD0. -
u�1�iLiH•
LA QlAtT A
77I,-RdU
C$I .ff,
USE OF PERMIT
AIX) 10(411.1 00-hZ, 118
1 . FUNlATE.) COST OF CONI S RUC110N
209.00
i'.VIKAMIT YE SfUNIMARV
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LESS i',E�H-t���IT�£EES
[JAY -1 7 199u . ' t ;. RS ��xf�� t�c�ry
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RECEIPT
DATE .
BY,,,
DAT ALE
INS--- PECTOR
t , ,
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
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 PI . Test
Final
Gas Piping
PLUMBING, APPROVALS
Gas Test
Electric Final
Waste Liries
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:
Appliance's .
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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Contractor Address
Own csr Job Address
This form shall be posted on th job with the Building RnslctaionUCJd at �ll 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
PIPELINES
CEMENT/ -
FOUNDATIONS
CEMENT/WALKS
6 DRIVES
ASPHALT
FRAMING
STEEL/
STRUCTURAL
MASONRY
PLUMBING
LATHING
DRYWALL
PLASTERING
HVAC
ELECTRICAL
ROOFING
SHEET METAL
FLOORS
GLASS/
GLAZING
INSULATION
SEWAGE DISP
PAINTING/
DECORATING
TILE
CABINETS/
INSTALLATION
ORNAMENTAL
METAL
FENCES/
BLOCK WALLS
LANDSCAPING
OTHERS
MA
` RIVERSIDE COUNTY
VNTy FIREDEPARTMENT
MENT
Si:904
210 WEST SAN JACIIr"I'0 AVENUE 9 PERRIS, CALIFORNIA 9237'0
(714) 617.3183
UM HARRIS _
COUNTY FIRE CHIEF Date;
Tos � a.., Planning Department
Surveyor's Office
Building and Safety
The Riverside County Fire Department herway releases the project
listed bwlows
Lop Number i /0 ? i U -s^a2
Add rose; /-2 6 C 1:�/0 /
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CHECK: ONES Final Recordation
Further Development
Meter Set Only
Shell Final
Tenant Improvement Final
Final for Occupancy
--------------------------------------------------------
CHECK
.v-----rwrwwww..www---- -------w...-..--.r----w-w-ww----w-CHECK ONE s X Fiee+s Paid
Few% Not Paid
Fee% Not Required
I1 you should have any quwations regarding than matter, please do
not hwsitatw to contact the Fire Department Planning- Section
Staff.
RAYMOND H. REGIS
Chief Fire Department Planner
,
by s ay'"..�.L'
REL92.10/92 FIRE PREVENTION DIVISION
PLANNING SECTION
o RIvv=s OHCS M M10 OFFICE
7760 121h Jm". R1ywrW, CA 92101 79-7)) Cowuyy a" DHY*, 9ulw P, Indio, CA 91101
(711) 11SA771 It FAX (114) )69,7451 (619) 312 -SW • FAX (619) 775207E
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