9606-174 (RPL)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
-PiNessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
47�?t�ti3. �# 16r3iI:�i
Date '� '> Cy%.Signature of Contracto /�.r-h t' ,i''�- –oee .r/il..-
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that Lam exempt from the Contractor's
License Law for the following reason: I.
.
( ) 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).
( . ) 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit istiM4d-.1W workers' compensation insurance cAVON&7p'tolicy 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.
Date: r•,a. Applicant 44e -r
Warning: Failure to secure Workers' Compensation coverag� 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, indemnity
& 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
correet. I agree to comply with all City, and State laws relating to the building
construction, a,Nd hereby authorize representatives of this City to enter. upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) '±'�„' �^ rs+.1 Date ""�''� �•
PERMIT # CONTROL #
BUILDING PERMIT 9606-174 3638
DATE (� VALUATION $�,4,'0 00 LOT TRACT
JOB SITE,
4 -615 VIA F.�aOKN.r�VCE APN
ADDRESS 6141 -110 -OU
OWNER CONTRACTOR / DESIGNER / ENGINEER
LArae:AV 7.X:A! CO INC.
47 435 VIA FLOPL NCE 925 A il.f-ii ri):t° , CANYON, N D I
LA Qj)IN"1 A CA 922+3 PALM SPMOS C A 92263
(',W5)328-2277 C131A 37,87
USE OF PERMIT
N'{)OL A.NNOk SPA
POOL & SPA ONLY
D ,` OI � � ,>; , �S DU lig �rOry
JUL 16 1996 '
RECEIPT I DATE ' I BY I DATE FINALED I INSPECTOR
14,1000.00
$343.45
${.tA)
$34.`8.45
PEWMITYCESUMMARY
PfAN Cf3tt?t` K WE
-V.9319
C
.11014J04
.101-00-410-wo
J51
514.4005
Nt
101.000-421.4100
$V1.00
M -F ,ECI'R W7A , FRE -- POOL
101-000-4204)00
$45,00
P[a,?IAA�ik;IN0,'Fry -.4,0 1, .
101 -000 -419 -Mo
V7,00
D ,` OI � � ,>; , �S DU lig �rOry
JUL 16 1996 '
RECEIPT I DATE ' I BY I DATE FINALED I INSPECTOR
14,1000.00
$343.45
${.tA)
$34.`8.45
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
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
lj .
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)
V