9609-177 (RER)U6ENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch�upter 9 (commencing with Section 7000) of Division 3 of the Business and
CQ UJ Pfbfessionals Code, and my License is in full force and effect. -
M License # Lic. Class Exp. Date
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c6 OWNER -BUILDER DECLARATION
_J 0 �
uu |oemuyo#innunda,pon��ofpe�u��a�|amaxompxhommoCommo�,�
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Uoonow Law for the following reason:
Z ( ) |, aoowner ofthe property, o,myemployees with wages axtheir sole
compensation, will dothe work, and the structure ionot intended o,offered for
sale (Soo.7o44. Business uProfessionals oouo)
( ) |, as owner of the property, am exclusively contracting with |inonoad
contractors to construct the pn8om (Soo. 7044. ouoinoxo &. Professionals
Code).
ce)() |amexempt under Section _______.aapC.for this reason
LO_____�_~_
N ooxo Signature of Owner
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< WORKER'S COMPENSATION DECLARATION .
C)�� | hereby affirm undo, penalty of perjury one of the following declarations:
«z'��� ()| have and will maintain ocertificate ofconsent mself-insure for workers'
Y= oomponooxion, as provided for by Section 3700 o/ the Labor Code, for the
C)�� pnom 'ovmowom�,wmvhmiano,muioioouou.
ED< (=),,rhave and will maintain workers' compensation insurance, as required by
C5 0 Section 3700 of the Labor Code, for the performance of the work for which this
o -LO po,mit isosxogWy*w,xom' compensationinsurance ommwr'm�m/my no. are:
Cartier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
_J ( ) | certify that mthe performance o,the work for which this permit is issued,
| oxan not employ any person in any manner ovaombecome subject mthe
workers' compensation laws ofCalifornia, and agree that if | should become
subject tothe workers' compensation provisions mSection uroocxmo uuuo,
Code, | shall forthwith comply with those provisions.
oato:---------- Applicant
Warning: rai|vmmsecure Workers' Compensation coverage is unlawful and
shall subject anemployer mcriminal penalties and civil fines upm$1oo.000. in
addition mthe cost mcompensation, damages aaprovided for inSection o7os
orthe Labor Code, interest and attorney's fees.
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IMPORTANT Application iahereby made tothe Director oxBuilding and Safety
,o, a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application iomade & each person ot
~~
whose request and for whose benefit work ivperformed under nrpursuant m
any permit issued aaa result v,this appnuamnagrees to, & o»on. indemnity
& hold harmless the Qty of LaQuinxu. its officers, agents and employees.
o. Any no,mu ioaveu as o result o,this application becomes nun and void if
work is not commenced within 100 days from date of ioouonoo of such
pe,mit, or cessation o,work for 180 days will subject permit to cancellation.
|uertify that | have read this application and state that the above information io
correct. | agree tocomply with all City, and State laws relating tothe building
authorizeconstruction, and hereby ity to enter upon
the above-mentioned property for, in Be on purposes.
�r, i r/,P. L7
BUILDING PERMIT
9601P-177
DATE. '91Z(d9i6 VALUATION LOT . TRACT
JOB SITE
55-634 *11VIKKA,
APN
769-412-020
ADDRESS
1
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
55634 IUMERA
/9-9201- DRM:3
LA QUIWI-A CA 92251
LA QUINTA CA 92253
CALN 3212;
USE OF PERMIT
P1.1*1"MIG FE116, 101-00,01419-000 $33,00
E
$18380
LESS IRE -AW
TOTAL 114301111' VVEN Df JC NOMI
DATE FINAL
A,_
INSPECTION RECORD
.� OPERATION
DATE
I 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 APPROVALS
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 ew
Utility Notice (Perm)
COMMENTS: