0004-004 (BLCK)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 -
'7C4210 C29 03l'3 U2(
/ate Signature of Contractor All w!� C
9 �
OWNER -BUILDER DECLARATION'
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) ` 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
h
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.
(� 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 isst�sYd.lv�yw4��s'.i��mpensation insurance car' �erA&lp19J4yo. 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 Califor,regand agree that if I should become
subject to the workers' compensation of Section 3700 of the Labor
Bode, s/�all f rthwith comply withA o e•provisions.
ate: �r/ '� ��ApplicVant�n
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civiljfiRes 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
correct. I agree to comply with all CY
construction, and hereby authorizVr5p
the;
he adove-mentioned property for/inspe
knature (Owner/Agent)
Mate that the above information is
State laws relating to the building
itatives of this City to enter upon
purposes.
1% Date
A
PERMIT#
-, (�f" BUILDING PERMIT 04
ATE VALUATION $1,523M LOT TRACT
JOB SITE 79-389 ,I.s CAE VWFA VERDE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CJLWIiAN 1' AI+f:C3 VM LL.A1v1S ASSOC,
'INKY YANEZ .TR,
77-900 AVENUE OF 11E VrMTY;:
72372VIA i KH,
PALM. DES1a't2.'I: CA 92211
RANCHO IYMRA rE CA 92270 ..
(760)328.2272 CDIA 38
USE OF PERMIT
0 r1 0 n t axr n ! 9 eu vcis •7n t v l.7. ee x
nraer trvm n veru trT
WALL
,1
u 1
5 FT. WALL 12, 001.F
4 tr"r. WALL 79.00 LE
`iiVi'A CULT Or C4)Nl32JG"T10iv
1,23.80
PZs'.Rwr ri EE
CONSTRUCTYON FEE 103.000-418.000 d 437.00
APR
0 3 2000
-PITY OF
Uk QUINT,
f
x
SUS -TOTAL C.O. it1.1-CMION' Ai3.(5 PLA14 CHECK
$37.00
aS PRE -PAM FRES
$0100
TUrAL PMW111 PEES DUE 14OW
$'47.00
s
RECEIPT
DATE
8Y
DATE FINALED
INSPECTOR
Imo®
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 i
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
s¢ F __94
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Lp • 1 •
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final f
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
Utility Notice (Perm)
COMMENTS: