9909-259 (PLBG)54730 Avenida Alvarado
LICENSED CONTRACTOR DECLARATION- {
•I hereby affirm under penalty of perjury that I am licensed under provisions
-„Chapter 9 (commencing with Section 7000) of Division 3 of the Business ar
`"Professionals Code, and my License is in full force and effect.
License'i - Lic. Class Exp. Date
i EBS C21 C42 I!
Date ` )r! Signature of Contractor4•}r''y •_”
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OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their so
compensation, will do the work, and the structure is not intended or offered f
sale (Sec. 7044, Business & Professionals Code).
( ). I, as owner of the property, am exclusively contracting with license
contractors to construct the" project (Sec. 7044, Business & Professiona
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 declaration
( ) I have and will maintain a certificate of consent to self -insure for worker
compensation,. as provided for by Section 3700 of the Labor Code, for &
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required t
Section 3700 of the Labor Code,•for the performance of the work for which th
permit is issued. My workers' compensation insurance carrier & policy no. ar
Carrier Policy No"
SiATEi%U 1) .15
_3401
(This section need not be completed if the permit. valuation is for $100.00 or les;
() I certify that in the performance of the work for which this permit is issue,
I shall noVemploy any person in any manner so as to become subject to tl•
workers' compensation laws of California, and agree that if I should becorr
subject to the workers' compensation provisions of Section 3700 of the Lab
Code, I shall forthwith comply with hose provisions.
date:275i3Ot r'f`. Applicant
r
Warning: Failure to secure Workers' Compensation coverage is unlawful ar
shall subject an employer to criminal penalties and civil fines up to $100,000,
addition to the cost of compensation, damages as provided for in Section 37(
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit .subject to the conditions and restrictions set forth on h
application.
1. Each person upon whose behalf this application is made & each person
whose request and for whose benefit work is performed under orpursuant
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating to the buildir
construction, and hereby authorize representatives of this City to enter upc
the above-mentioned property or inspection purposes.
Signature (Owner/Agent) r' "% ` • > > <' '"' Date
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BUILDING PERMIT PER MIT #
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DATEfmi VALUATION $4 uZi1P LOT TRACT
JOB SITE
ADDRESS 54-730 AVENIDA:lCV,,U?A00
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OWNER
CONTRACTOR / DEESIIG N ER / yENGINEER
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JA•l.A (i,:,; yir.[ ..I WALES
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5 4-7i O AV :lrlln.t . A.1.VARJXi 0
8703; VXSr_,- DRIVE, '
LAW4N°PA CA 9,22 KI
CATHEDRAL CYR' CA. 9223
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(760.,1374. 191 } C'RLP 764
USE OF PERMIT
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VALUATION ION 2,500.001:•5'
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RECEIPT
I DATE
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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
POOLS - SPAS
BLOCKWALL APPROVALS
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
`A
457
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
Wity Notice (Perm)