0002-052 (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
674074 is 07i3�2tii
Date i Signature of Cori ractor
OWNER -BUILDER DECLARATION
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 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:
Cartier Policy No.
SCAT; IIJNWi (f ftO10733S
(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 manners ao s t-o"become subject to the
workers:, compensation laws of California, -and agree At if I should become
subject to the workers' compensati n,p ovisions of Section,370a of the Labor
Code, I s forthwith comply with,those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up toz$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 thisapplication 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 representatives of this City to enter upon
the above-mentioned property 'for.inspection purposes. �� b'
c� l
Signature (Owner/Agent)--•'y Date
PERMIT #
BUILDING PERMIT 4A10 4*1
DATE� VALUATION(!i't.y>)7.2 LOT 1� TRACT 24i0>7i
PA
S 4&514 IrIST A .>'C.diC� ENO JOB APN
ADDRESS 649-100-Gd35
OWNER CONTRACTOR / DESIGNER / ENGINEER
,r'ri r,%vt pP r imixtiJ? nn+ 4vrK.rr A:0 AD Ep I` �.tC'i"??i
A! Rt1.:0l-.A%a. 1,/A,+ b.A....,al��A �♦A. GAY A. ' --A f'lA 4A�AD b 1s Va.f t. li,AJ . a aY
P0 Box 1711 )-243 RANCHO LA QUIN l'A. Ilk.
1.A QUINA CA 32253 LA t, UI TA. CA. 922}3
( cilJ17 1-l9�i� C'BL dl2(�)6
USE OF PERMIT
,►1PNULI� PANft.. Y' !_li+V irIL'i &i:
11001- 7ti�-*.PLAN CNEO%' Fick, XV_r1UC~T.1_0N FOR MULTIPLf;1S:SUA.NCS,,(.)'
0AKA4.ikS/CoAWPURT 693.00 V
11-,'STT1i1XrED COST OF C_'ONS'a"I U 110"t
260.917.20"
PERMIT F111, GlJMI)d ARN
ILYDNS'1RUCTRYNFhJ_-'
101-000411.8-M
51.204.00
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10140 419-000
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CTRADING 'V=,'
!0A1 000-423-000
$20.00
ials 't;1.c;�aA> 12 iiomc:r,1.t:
$1,907m)
Adt'1 a'N PUHIsW PLACES S - 'lif 1(31-000-255S-(9(1.0
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RECEIPT I DATE
DATE FINALED I INSPECTOR
T4117 47
SUIX?
S4,31.7.97
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�—
f{/
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
'Combustion Air
Roof Deck
Exhaust Fans
CK to Wrap
F.A.U.
Framing
—pz� �p
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans &•Controls
Party Wall Insulation
Condensate Lines
01
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
_ IN
Final
_
Final
POO S - PAS
BLOCKWA
A PROVALS
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
CO' 11-
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
fir/
Gas Test
Appliances
Final
COMMENTS:
Final
4/PAC,'< :T (1a 6�
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
'100 oe
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power 00,
14
Final
Utility Notice (Perm)