9611-063 (AR)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
N W Professionals Code, and my License is in full force and effect.
F) Z) C,) License 1 Lic. Class j Exp. Date/
LU
I1 .
Z r- ate t el X�_f-Signature of ContractorCID 0
OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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 & Profession.al.s 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
L
N Date Signature of Owner
ON
rn
d< WORKER'S COMPENSATION DECLARATION
p 1 hereby affirm under penalty of perjury one of the following declarations:
Lo Cc
� Q () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q C) ) I have and will maintain workers' compensation insurance, as required by
Q C)Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier &•policy no. are:
? Z Carrier Policy No.
ob 5) `a`I'Acam'.111AND 137109*5!M
O
(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 whicthis permit is issued,
I shall not employ any person in any manner so as to 1+com subjectoto the
workers' compensation laws of California, wand gree that if I ishould ecome
subject to the wgrkers' compensation provision of Sect on 3700 of the Labor
Code, I sh lI forthwith comply with those pvisi o S. �1
date: 17 JL'/ 104 Applicant—
Warning:
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminalYpenalties 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 tor,
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 stte that the above information is
• correct. I agree to comply with all City, and St to laws relating to the building
construction, and hereby authorize representatives/of thi °City to enterfrupon�
the above-mentioned propertytfor inspectio pdrposes.
(
ignature (Owner/Agent) ! 4 `�� Date
BUILDING PERMIT PERMITk °ONTR°`
96#1_063 42462
DATE t2fl(I/+VALUATION $,trLOT TRACT 7
JOB SITE
ADDRESS 79-045 VIA CAUM L
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1*11.ISERTINEVE i:.0?PME INT
St'ARIK CONS-fR•;:Jt; i �: N
1'.0. tiox 17W
791,95 KANCi' O L.A t" tUI'i3IA DR.
4A 01J[ l rA CA V2253
I.A. Ql ANT E1 CA. 921253
(019) 714941 CSI..#€ 2996
USE OF PERMIT
RES'JIMa` "IlAt..Aial:J.t'7"I(W
ADD 1,90 S.F . T 0 A3A6A k00Jvt ($1 L_ 62s.ou vAusAT to -R) AND TIO
S.F. OF (; .)VEId1:1:A P(.iite, 4 (S 0911 AA) VAf.UA`E'tc:iN).
J' DVIOD0. - CUST,01ki i 11Q8.00 rS Y.
t 012( -41PA 110 210.00 S
tW11$iA'l ED [:'ONI til' C;ONS7"RUCHON
1 ,21.33
PICIII(Alff FCC SUMMARY
CC)NICO Ai{'"1"IONA FIVE t71.0(1
h!t•;COANUCilU, r 1, 101-000-1221.000 $15.00
6L I '.-CT Wt CAt, IE6$1.:1+1
SNI+RA311'bt0717 R R 10 25.000-44-1-3112 $26-163
`3TflNtl�+ti"i'b'1'i"ftilf:4�I;wt?�!Clt`► !('ii�ti(if1-?.Sl-f.f1(1 $1.52.
,rpvtY1rA6,C`ONS"Ilk( Q'.(ON NND MAri! C�y(J;c�,.�
�gtxx 6"0
ITV OF LA QUINTA tt L1 SS:PHIL,-PAID FE P'S
$00
DEC 1 9 1996 Dup`No w
$1581.60
FINANCE DEFT.
+•
9RECEIPT
DATE
BY `
DATE FINALED
INSPECTOR
P+
1 .
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.
Griffis
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:
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)