9812-211 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H _ `=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.
License # Lic. Class Exp. Date
Q U-) 7i4189 i9 1i1:_"si1991
LU
r Z � tor
Date 7- S Signature of Contrac
C�DQr
J U C OWNER -BUILDER DECLARAT ON
U U I hereby affirm under penalty of perjury that I am exemptfrom the Contractor's
F— a License Law for the following reason:
Z_ ( ) 1, 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).
ce) () I am exempt under Section B&P.C. for this reason
L
N Date Signature of Owner
Q N
C7
2<
WORKER'S COMPENSATION DECLARATION
o 2 Z I hereby affirm under penalty of perjury one of the following declarations:
U-) H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X U 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 U ( ) I have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
I'* Z Carrier Policy No.
t r.; t ACU INS. NIVVC; S ;v.5S-'0i;
orD Q C,jt�lg,�rc:i`L s.,i`
J
(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall fo i h complyr-thsedpro isions.
Date Applica��it' . r A � . A�
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 FiIS
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
• 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 i specttih purposes. t
Signature (Owner/Agent) Date a
BUILDING PERMIT PERMIT#•�;:
DATE VALUATION S j 1¢}AH&IO LOT 1 ol, TRACT 27494
1- '7
JOB SITE
9.09(f vicro,9tul alavck
APN 604-371-015
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
{'f-,N'TBJP:Y CftU,',Vi'd.l'. L CONMINMIIN14111E" ;
CIcNIfUft ' C Ct N41*,;1.Ryti,r1E S
1535 aCi. 'fir' 91'RL,' i', IS"iR #22,01
1535 SO. "i)" M:EET. 91T. A200
SAN BI NA.)t: INO C,A. 92408
SAN B67KNAMNO CA 92408
(,'.,()9j;i8!4()()7 fCIVI 21' 1
USE OF77PERMIT
SINGl`��
P, f At�41L 1' U VY.'�.7.+14d1y1J .
Lai 1,07,1:J,.AN 275-3 SFD - PERMIT DOES .NUf Ilvc°LUDR EL.OM
WAf,L 3 <.}b't .!''001., PL,AK C;iffiX:` 1 FHOt 7:w'/n-1r,"O t `M.EII.`!TP
[&'A1A'NC*F 0F .tA :PLAN TYN(3..
I CAC CO STR CTION i ,��_c.00 s r
GAk.,k iDCA12.10RT 642.00 SF
9: iS11,i4b98tE1,11) l-.'V.DT OF \.ONWHV4�.�i\.fltr
.a'U,433V.s0
PERMIT FEE SUNIMARY
C QN Tk'!l<;TION FBE 101.40)-418-0011$6114.Ui)
rf 'kw C"wt: &e
ia.IE U NI AL nlcl tfit r -i x,'00'0
1440 1[ %iL Fm 10 i -Mi- Q10-600 S124.45
PLf.f 4HJNQ h'1rk 101-000419-M)
ltif(93'YI+Prf►�IFRr s�VRR) ).ff1�i>tT}�6r+Vt1 4f7 -:(U10
ppc��+ic t?f�Y1nntib
etih,F DI ,11C, PLiE .101-LNA2..3.00V $s2 ,00
IiGICtAiti'l141) "3'Ur@RiFEE 225.000443-A, 42 *Z485,94
ART IN I'dtf31::1�G "Mt.�lt`.F_S'- Zt�SfC fi�1-UUtl-2S3dit1tl S26.,U
�9 pp 1 1
Yf'M, C ONS"r1tI: TIION :AINO PILAN CHECK
MrSS PRE-P.AIV FILMS
1:0,00
it .J
r JAN 07 1999, II,.i �.�,.9 A ,af,� IMF, NOW
$4,09,6.46
K l
RECEIPT
DATE
BY, .!
DATE FINALED
INSPECTOR
f ,.
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 3 3 9
Exhaust Fans
0.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
DWwall - Int. Lath
Final
Final
BLOCKWALL APPROV LS
POOLS - SPAS
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
Gas Test
Appliances
Final
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 4a a
Utility Notice (Perm)
COMMENTS: