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LICENSED CONTRACTOR DECLARATION
I h;Qby 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 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
Code). Or
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner .i 0 tr
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
(V)/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. 1
Date:. 4.. 1 Applicant '%- A » -, �� a1� .) lb., .. ✓
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 authorize representatives of this City to enter upon
the above-mentioned property for inspection p;p as, .
,Signature (Owner/Agen) � ✓' /ll !�i.� l f / ?/} �l �a,Date,'S��
BUILDING PERMIT PERMIT#
CONTROL#
512
0
DATE 91.3/97 VALUATION S,Z "00+01,1 LOT TRACT
JOB SITE
APN
ADDRESS -.1 �U C �3e1l. � i .S'1'liilii� :�Et1,�'11✓ .1117
769-10t-017—
OWNER
OWNER
CONTRACTOR/DESIGNER/ENGINEER
G E"RA1,D t1€ 00AN'
OWN BUILDER
PO BOX,139 7
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USE OF PERMIT
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$14:1.119
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
_Ww''I
-W I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air a
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing -/ _
Compressor
Insulation -- G -�j
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
POOLS - SPAS
BLOCKWALL APPROVALS
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 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:
t
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fuhures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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FAX
G. BOGAN & ASSOCIATES, INC.
54-368 INVERNESS
POB 1397 LA QUINTA, CA 92253
PHONE (619) 771-8400 FAX (619) 771-1901
CRATE:
T0: �-! e CFS c3ty�b
ATTN: SL -v"
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FROM: Gerry Bogan
SUBJECT: (3� a� �•�-S
MESSAGE:
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05. 13 9 i 10: 21 F kX 564 5321 3IS3I & ASSOCIATES Z02
MAY -t3-97 TUE 9:34 CITY OF LA QUINTA 7607777011 P.61
CITY OF LA QUINTA
SUB -LIST 5705 -Owo
:ONTRACTOR ADDRESS P V LOO
IWNER JOB ADDRESS rS -I ae-) CA de 4t_b4Acxn 20-7
'his form shall ba poated on the -lob with the Bullding Instiltion Card at all times In .& conspicuous place.
is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that
re on this list are the same persons performing the work. Any changes to this list must be approved the
:ity of La Quints Department of Building & Safety p m to work being performed by a changed sub-
ontractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit.
TRADE
GRADE/
EXCAVATE
SUB -CONTRACTOR'S
NAME .
TYPE OF.
LICENSE ::...::.
A/C -12
:. .:.
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CQN'tRACTQR'S `:_ :.
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LI
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WORKER'S
COMP; NAM
> ....
NtiMBER
CITY ,.
BUSINESS
LICENSE: ...
:..
NUM8ER1: :.
FJCP. DATE
PIPELINES.'
C-34
CONCRETEf:
FOUNDATIONS
C-8
ASPHALT
A
FRAMING
a
STEEL
STRUCTURAL
C-61
MASONRY
C-29
PLUMBING
C-36
LATHING '
C-26
DRYWALL
cu_-A)i
C-9
PLASTERING:
C-36
HVAC
C-20
ELECTRI
GenereflCAl
'C6G
o-10
J3 f a433A8
aogS?913-lam
%
30,-j'a '%7
ROOFING
C-39
SHEET METAL
C-43
FLOORING'
T4%-NTrAP-10IQ- ACC900TS
C-15
GLASS/
GLAZING
C-17
INSULATION
C -Z
4
3%Q34
1
03 I q
SEWAGE DISP.
C-42
PAINTWta<IQ��
DECORATOM
gu.+
C-33
CABINITS/
INSTALLATION
C-0
FENCING
C-13
LAITUSCAPING
C-27
POOLS
C-53
OTHER
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