9611-062 (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 B siness and
Professionals Code, and my License is in full force and effect.
License # Lic. Class / Exp Date
15 I7Q~I/ i i
Date ' ' Signature of Contractor 1 r
OWNER -BUILDER DECLARATION Y
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 wiih 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.
V) 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 thi perr�It is issued,
t
I shall not employ any person in any manner so s to trec3 a st<ibJect to�the
workers' compensation laws of Californla,land agree that if I should beeome
subject to the workers' compensation provisions of Sec on(370d of the abor
Code, I sha I forthwith comply with those provisions. % I
ate: "� ` Applicant-
Warning:
pplicant 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. 4
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 tate that thegabove information is
correct. I agree to comply with"all City, and State)rawsrelating to the building
construction, and hereby authorize repres ntatives of/this City to enter upon
the above-mentioned property for in/s`pec ion purposejs.e
/,,,nature (Owner/A ent) i �'` i } + Date 121/1"1 rl
PERMIT # CONTROL #
BUILDING PERMIT 961. A'
-458
DATEWrTh� VALUATION S1.1%Z' %00 LOT 17 TRACT ,
JOB SITE I
ADDRESS .79..015 VIA CARMEL
APN 64321 OAUS
OWNER
CONTRACTOR /DESIGNER /ENGINEER
T. w1. i)t's:Fmwr )ktV1?i3O�'.MENT
Yf f
RRARKS CONSTI'.ir,'�,,. UN
P.O. BOX 1716
79295 RANCHO LA QUINTA..OR.
LA. QI.tIW A. CA 92,253
CSA,
st92A! (q��
(611)1)771-1941
USE OF PERMIT
USE
/uriJ 480 S.k. TO Q1 --WA'!"' t00f*4. ($11,628.igj VALUA'i iON) At%10 27o
8-F. Csv Co VEfi;L1) PO dci � 53..sq t,00 VAl..d,t IJON ).
Ploftc:CWKC10 00.0o *,g;
R811rl,9kiTED COS'T OF L:fa1L;S' UC:II ION
M2.19.00
°�It2J�'#!'i` :Lt's+;� !�ttiE►'dPJ'�A.`ttil'
PLAN4'H[Ck' FF17 tCli-UrJfi-f3ca.{1$ $t#1,.!.S
Cid 't t Cf!�T)rtiN) cr1 It?t.-tT f1-j339.000t?t.nfi
A4JI TIANICi• L ITN 103.000-,4&t-010
h1.1:C:I'#2.Et..Af.1 R i!t!i-OW-4:04M S200
INk'fiASC'!�13i�3.9tl2fii 4a 22."00 13-3492 $2AL63
;:;'t ►Id(� AsfY) ir.it+! f ; !a 17r yt>3 101-'t!i()-24t -i}cI0 -:S
a =
SI:1ITAL, C;QN:Mtl,XTIC7N •1:N'n P1,AN CfI PCK
CITY OF LA QUINTA LESS PKE11-11A.II) l RIE's
$000
'f-OTA1, ��:I RAIf1' Ili�,,YS, 01JC't 0W
$58.1,MI
DEC 1 9 1996
FINANCE DE } ,
RECEIPT'O DATE
BY
DATE FINALED
INSPECTOR
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater 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)