9909-184 (BLCK)LICENSED CONTRACTOR DECLARATION 4
I hereby affirm under,penalty of perjury that.l 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
42338) B 07/311 1 20i
Date S ! � Signature of Contractor > _�
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 c'ertificate,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.
a •f..0 ^fi.• }: 0- fl. f!1 f NLftttMi
(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
subject to the workers' compensation provi ions of Section 3700 of the Labor
Code, I s all forthwith comply withtth`ose pr1TVisiQris:
Date: t Applicant \ t. -t e4� t
/Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up, to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person.at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance. of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and herebyt*authorize representatives of this City,to enter upon
thabove-mentioned propertty`for inspection purposes,—
I/ lgnature (Owner/Agent) SS Date
PERMIT# �rh:
BUILDINGPERMIT
DATE 1)91'$ If VALUATION t&1JJ)ll3 LOT TRACT
JOB SITE
ADDRESS 52474 AV EiNWA g}.L1.RE1` Ut�
1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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rs.1r'r�.-srY�r^�,�'eec �r��,).e ��c+r trvrart•t.r
1., \.. M1 34. if r!' ../f,. l,l 9-. t,� 20.l!ti.• If.J:b
N ts1i;E.ANMUE, CA 92.054
Chi. 92054
y,-
USE OF PERMIT
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COTNI'TrRuc, t`1ohf FEE 1101 -000 -419 -ft') �iS t►ts
3TfZ=fd'yi'Ai':f:(1'PtS:�'R;tt-'PO N AND Pf-AN 01F:E!K
T,ESS PRE.-VAID FEES
DUE NOW
915.00
RECEIPT
DATE
BY 11V
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE,
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts i
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 8 Controls {
Party Wall Insulation
Condensate Lines
Party Wall Firewall
{
Exterior Lath
{
`,Drywall - Int. Lath
[
i
i
Final [
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Hacks
Electric Bond [
Footings S
Main Drain [
Bond BeamQ I 5
Approval to Cover
Equipment Location [
Underground Electric [
Underground Plbg. Test [
Final /�
Gas Piping i
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
I
Gas Test
!
Appliances
I
Final [
COMMENTS:
`
;
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)