9912-087 (RER)',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
483540
�Jat�r /e7
12 Signature of Contractor �f
(• .y OWNER -BUILDER DECLARATION .
Lhereby affirm under penalty of.perjury that.l am exempt.from the Contractor's
License Law for the following reason: /
( ) I, oo ownor of tho proporty;: or my omployove with wages ae thgir sola
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 (Seca 7044, Business & Professionals
Code).._
O 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 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
subjeet to the workers' compensation provisions of Section 3700 of the Labor
CCde, I sh II f rthwith comply with `thes provisions.'
'
ate: �� Applicant
yearnn: F iure to securWorkers' 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 Applicatiori 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 for inspection purposes. ,
Signature (Owner/Agent) (/ G Date
PERMIT �� ;-
BUILDING PERMIT -: 2(197 .s
;. 9 '
DATE.j t VALUATION $J,2,0f%,00 LOT 1 q, 1.6 TRACT 111297• U27
, y f
JOB SITE! 5 f 0 I1WENHMER )DRIVE>✓
7719421-069
7APN
ADDRESS
OWNER
CONTRACTOR /DESIGNER /ENGINEER
it3sCyyTAS AKi]
..r
AYCarLAwLA,fr.iRS
745 S. A9:faLINGO
745 S. E1VL ENDO
_
PASADENA Cel. 911W
PASADEaN.A. CA 91106 ;
02())584-4844 Cts[ # 571211 ,
+ .'
USE OF PERMIT
R.E?EIDMIAL RI-NODEN,
,
6'"i7EK.I;TNO, 4TAL PER -WIT i'O.9WA-256. ADittTION OF POWW)YU- `c ROOM
BAT N, W91' 5AR @ 1GRFA;C ad.<vl0N1 & 1SLAND COUNTER W.1TU.i'Rip w3;;:NK
iNKi'E'i,Y8 EN. 0NLY - NO ADDH0 39PARE FOOTAGE) .
i'.Flt:.ts)kS.EiV' - - l,200.00 LS
.
1 11NI T1,112 COST OF CO.N:STd ILIC`t`IMN
P'.E.RMI Pt+ SUN4AlA14Y
. '.
PLANC-HECk FEE E.1114*0-439-•3112
CONS Y-tLY •°i' ON F033 101 -(f()0 -4I8, .1l) +29.t1f1
ci1'sC'CL•tt ^,AL;.+., ; i^3-f}CO-4nQ tlafl $35.45
'•
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•
SWUNG ], iAYr taN ..FJEE " RESH> 1.01-000-241-0W
-
`w:i V
311$
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,`j+, `7;,l i ll}Cytt�1�C°f�1rvS1'Jta7t; (' E f J? gr ? E+iS•}SF;t;;n'
',� tq:1(y! 80 ...
LESS Pk&P A l:t FEES,,
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.iTO'§AEt,11+?b:!;RMJJ; 1 EEE .!)@1.1+;'i 0NV
`�14}e X59
RECEIPT
DATEBY
a -;�
D N D
INSPECTOR '
a
� 4
i..
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS e
Set Backs
Underground Ducts i
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air = t
Roof Deck
Exhaust Fans f
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
POOLS.- SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond 4
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location r
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING A PROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure I
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
4
Final
Utility Notice (Gas)
CT" RICAL APPROVALS
` :;.
Temp. Power•:Pols
Underg*nd- Cojiduif , t
Rough
Low Vokage Wiring:
Fixtures •_s
Main Service:* •.r
:,
Sub Panels_. _• .
Exterior, _Receptacles
G.F.I.
Smok® etectors ±-
Temp. lJse of Power`
Final
Utility Notice (Perm)
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