9311-109 (BLCK)LICENSED CONTRACTOR 'DECLARATION
I hereby affirm 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. 3g185i Ltd) vj 1 M
License # Lic. Class Exp. Date
Date Signatureof Contractor
OWNER -BUILDER DECLARATION
I hereby affirm 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:
Carrier Policy No.
(This sectio(t!Fneed;•not& completed if the permit valuatio ti0,1forQ$).Q0.00 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: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, intarest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
A.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon'the
P.: nve-mentioned property for inspection purposes:
Signature (Owner/Agent) Date
ALC0
BUILDING PERMIT
PERMITS
DATE
VALUATION
TRACT
JOB SITE ADDRESS�tS$ii �:iGt�34
APN
OWNER
CONTRACTOR
:I F,1\'r�RttY yANFZ d A.1,`,0NEY -
iss'igil la i. �'y C La, Piz
La,
Icy 2 iAl VAR,
Q-100 Vista "Blow
RANCHO Wl3.E CA 92270
1•1a)ta ��`A��
693282272 CJL# J
DESIGNER/ENGINEER
USE OF PERMIT94jSi.,;,,},, i�*llj
BhNk Wilt 51,41, 0;-
Plamer (2) 2' (�i 201
FEE DESCRIPTION
FEES
51.7. WAIA. 26.00 Lk
FST MUT EID COST OF CONS T. adUCTION
52.90
I''E$Zl1 iT FEE UNT I.iA1ARY
r!;
SUB -TOTAL 6_f*TS; RUC'1T0N AND :FLAN C'j MCT_v.
LESS PRL -PAID FEES
$0.00
i'OitA.LP,R.OJir'O' f1EAdVI A!:fi. S
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
BLOCKWALL APPRO ALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground .Pl . Test
Final JIff I
Gas Piping
PLUMBING ROYALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Firial_
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:
�"no'a / OGc.iv7`/�/�ti
dA
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BUILDING
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GOND LY
SUBJECT TO IN A ION AS' PER
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LaL,uha De La Paz
,-P.O. Box 799
Ranch; Mirage, CA 92270
0519) 564-8864
FAX (619) 564-8867
� • ARCHITECTURAL VARIANCE REQUEST
UNIT # OC/SGS li! ��� DATE
NAME�j� Vjf(Jf�/2�i5'C its ..
L
STREET ADDRESS G �-
` LOCAL.PHONE # OTHER PHONE —�--�
To The Architectural Committee:
'We, the,'undersigned owners, request your -approval of the
modifications proposed.on the .reverse side of this form.
Attached are drawings,of the, work to be done; types of mates
:al
to be used'are indicated on the drawings. We..under.stand thz:
building permits for home improvements are required'by the city
of La Quinta and that the cost of the permits and responsibi.ity
of obtaining permits and subsequent inspections will be born:
by us
We acknowledge that•all approved changes in the original de:_gn
will be at our expense; that any damage to or relocation of
existing sprinkler systems, -'underground utilities, building
structure and exterior landscaping or other damage resulting
-
from construction of these permitted improvements will be at
our -expense; and that maintenance.of thg permitted improvemEits
-
will be at our expense. �.
SIGNATURE OF ALL OWNERS: