9709-113 (BLDG)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 nd effect.
License # Lic. Class Exp. Date
Date st[ 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 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 GOLIAN EAGLE Policy No. NIVIe=-X: 1,10-141
(This section need not be completed if
( ) I certify that in the performance
I shall not employ any person in any
workers' compensation laws of Cali
subject to the workers' compensati
Code,h I $?rt comply with
Date: � I Applicant
ippermit valuation is for $100.00 or less).
rhe work for which this permit is issued,
manner so as to become subject to the
rnia, and agree that if I should become
provisions of Section 3700 of the Labor
Warning: Failure to secure Worked;' 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 ,t
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 for80 days will subject permit to cancellafion.
I certify that I have read this appl' tion and state that the above information is
correct. I agree to comply with City, and State laws relating to the building
construction, and hereby auth r' a representafts of this City to enter upon,
t1�-aeevatmentioned property insilection purposes:—
Signature (Owner/Agent) Date
BUILDING PERMIT
PERMIT #
d>,.,.•
CONTROL #
5955
DATE 9r •3 IZ VALUATION .�, c�.tl �,i�i! LOT
TRACT
91
JOB SITE $;1.4--,: A 'ENIDA M.OaeTAUMA
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
c'LArmw nu : :.r..A
4I N1, CONS R1 C1r11.('%
lot LES iS�.i;3.l D.
'79-070 C;.t�.#.�.L , t;:;.��:C.3�L
CA 94611
1.AQfC1}li+;�f;4
A A
G'.
3253
_
,7N))564 -•4M— 2 (11•..
�(]1.174 626
USE OF PERMIT
FO.I biNt
404t �i�1e( tU i vi2:ti� 4i"i [t3if%
0 F &v ALI..
G(t i,??C '%KF
( 0.14 Tr24.t+"'Y:��_�0t
i�.17'A.�(v(D?Vt t�.i9
tllhif
LENS, 11"KE-PAID FEES
$0,00
SEP 2 4 1997
T01A), ME, K AIT
FCWS 0VP,NOW
CI 1 T ®F LA a.>id41? N 1 A s
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR)
BUILDING APPROVALS
MECHANICAL APPROVALS 5
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 A
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
40141ZI CZee
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Unes
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
Utility Notice (Perm)
COMMENTS: