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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 30
f the Bu inessrand
Professionals Code, and my License is in full force and effect.
License # Lic. Class / Zp. ate
6711074 iS
ate i I'3 a (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:
( ) 1, 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).
( ) 1, 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.
( I have and will maintain workers' compensation insurance, as required by
SOetion 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 t is permit' is issued,
I shall not employ any person in any manner so as to be ome su�iject to%the
workers' compensation laws of California, and agree that f I should become
subject to the workers' compensation/,provisions t of Section 3700%f thetLabor
Com°• tle, I shad forthwith comply with those provisions. !!
vt(ate: 1- : 11 " i : �ADDlicant l ,,-.r ; I-,
Warning: Failure to secure Worker`s' Compensation coverage• is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. p
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under.or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and statq that
correct. I agree to comply with all City, and Sta> law
construction, and hereby authorize representatives o
the above-mentioned property/ for inspection purposes
J 1
/Signature (Owner/Agent) f f%
above information is
Idting to the building
s City to enter upon
t
Date 7-rM
1
BUILDINGPERMIT PERM T#°NTR°`#
vb�� �f►� 4468DATE
TRACT .t� LOT %« '�K343
x�1 /y6 VALUATION S�`2xi
JOB SITE ADDRESS 78-863 V.i.A C;.iA%t.i1i1�'.i:,
APN 649-214-004
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T.D.
'SpA ITCS COMSMUC"'i ON
P.O. 80X 1716
M,05 RA N t:.H%i LA QUTi1"l A DR,
1,A 0111INTA CA 92219
i_,A QUIN'T'.A CA 92253
ffii.��)77T-19 i T C 13L3#
USE OF PERMIT
RF-Sii.li:t•}`OM. A.1.>t.)I'HON
&F. tali iXiVEXED PORC;li VAIA N1'1QN,3-
REhf0ikL - (. i i 0101t 1: r2.li. SY.
4tOR(IiftIW11.0 214koo "ifs
.ES'3'MIATKID COST OFCONSTRUCTION,
ZS.Z���tlQ
i•'3.ti.N f iECK. F7E 101 -CW -•439-31.$
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litis,.t.Nf�f3YFAf-rt�1,elr.l..f': IQT-0u°-�a:)^S3'J� $!„'i,jj,3
'
T't E'0310 AL Vz130
1!�ft t2 �.i t fEi ii ;fit d!♦ 1 FEE 2254YM-40.342
1`a'�; 2tyY7 A,Jn'1`f£ itJ iwl _ Rr2 s3Ell i f)t .(1(1(1- T-ft{jt► $i �'
y .
S€1kT-''IY:Y!",r L((-N.'A'12L1CT"[0N aNDIPLAN r71*X_X—
t.fm
LESS PIZE T'AT1a RES '
$0.00
iTY OI- IA QUINTA
'g'kVrri L PERMIT >Gt'.ERS Ir,03J.: NOW
�S�i1�f►1i
DEC 19 1996
RIIRlI "NAAI(�E
BYE
DATE FINALED
INSPECTOR
o
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
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 I I
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
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)