9805-064 (BLCK)LICENSED CONTRACTOR DECLARATION
I -h> .reby 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
301/00
ate /t ci ` Signature of Contractor '� �? , 1�74 I O
7` 11 %
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
Setiion 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.
TONNICARE 1[NS CO SC50-1197-14179
(This section need not a 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
ode, I shall foripwith comply with those Orovisions.
ate:�Failure
Applicant 1f' jE / _4 .
Warnisecure 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 representatives of this City to enter upon
the above -mentioned property foi( inspection purposes.
Signature (OwnedAgent) // vC Date /
t >,1
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION, LOT. 9,805.064 •TRACT
Z4 41 $3�,3117,60
JOB SITE
APN
ADDRESS 47-620 ivid i i II;CT�
"
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CANIA17AY & COMPANY
CANADAY 4 CC7NTANY
1570 BRt OkHOL1,;OVGf URJVE, SUITE 208
1S70 BROOK1 OLLOW DRIVE-, SLWIT' 208
SAINITA ANA CA. 92705
SANTA ANA CA 92705
t,1: 751.�t51 CBL# _985
USE OF PERMIT
QXRRDEN BLOCK WA1',L .97LF @ 6' f-.14D 44LF @ 4V
61:T. WALL 97.001.S MAY
14 1998
5 FT. ALL 44.00 LF
C.SITIMATED C 3ST OF C)NSIT.R.l7C'I'ION
PERMIT FEE SUMMARY
CONSTRUCTION FHE 101-0004.118-000 $0.00
SLAB-TWAI, CONSTRUC110N AND .PL•.AN CHECK:
$6100
LESS P14-PAID 1i"MS
MIR)
TOTM, PERMIT FEES I. UE NOW
$63.00
I
..
LA
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING. APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underaround Plba. Test
POOLS - SPAS
Final
I '
i a--
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
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
t
t
Final
Utility Notice (Perm)