9801-028 (SFD)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
tj4ir`i a t'` 3f1IiM90
Jbate / Signature of Contractor
OWNER -BUILDER DECLARATION /
1 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
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.
f'A Tf a f ffdT` 137 PY51597
(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'IIFCoOld become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sh`all,forthwith comply with those provisions.`
vbate: / � / �''� 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 authorize representative, of this City to enter upon
the above-mentioned property for inspection purposes. .
�v
VS gnature (Owner/Agent) r ��� Date
r
0 BUILDING PERMIT PERMIT. CONTROL#
/
DATE VALUATION S200 %Ao LOT .1 i4 TRACT L.V8
AA
JOB SITE!
ADDRESS "
APN
BS�«tU0-i3
OWNER
CONTRACTOR / DESIGNER / ENGINEER
P.O. WY'ti i 710
fGkW)' O LA QUIN VA 1914,
LA C U111TCA CA 92253
LA C.,a€. IN'i A C:,'.r`1 97213
USE OF PERMIT
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JAN
15 1998
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ti !'t2' ants l nsc� Yt:�i41 H`OF — RRS 10 t01 _i)m
IN4�tCa�«:T1>3$4"1(i(C:f� 225-000-4,13-342
AAT IN PU f,W KtV,'.F8 - ftESID 701-000-2,55-000 V'O6A1)
ART tN K13"4T,IC P1,.t VYt 3 -3401,49
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LE -88 PRW-PAID FEES
I'MAL PIERATIT FEC'N MIT' NOW
�7,%7il,e1T
RECEIPT
DATE
By/ `"
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
i G
Forms & Footings
- p
Slab Grade
-/a -
Steel
Roof Deck
O.K. to Wrap
20-
LGA
Framing
-
PLUMBING APPROVALS
Insulation
Waste Lines
/ ,
Fireplace P.L.
Water Piping
Fireplace T.O.
Plumbing Top Out
Equipment Enclosure
Party Wall Insulation
O.K. for Finish Plaster
Party Wall Firewall
_
2-2
Pool Cover
Exterior Lath//11
Encapsulation
Gas Piping
Drvwall - Int. Lath
/D /ii
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air G -2
Exhaust Fans ✓a`-7
F.A.U.
Compressor ^�
Vents
Grills
Fans & Controls
Condensate Lines
-
BLOCKWALL APPROVALS
POOLS - SPAS
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
tAll
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
2-2
Pool Cover
_
Sewer Connection - 2 6 `V
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
UnderGround Conduit
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)