9703-109 (DEMO)LICENSED CONTRACTOR DECLARATION A
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
tb :200 2„� t M.A.lf9 r
Date `'� - f- f7Signature of Contractor, /,-•7 i
4
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.
Se( ) I have and will maintain workers' compensation insurance, as required by
ction 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:
Cartier p tD Policy No.
l•
si sE tiilrWA 60,- 1dY.: 3117_%.
(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
E56ject to the workers' compensation provisions of Section 3700 of the Labor
ACode, I shall forthwith comply with those provisions.
1/ Date:' t` `�� Applicant Z�,��"'�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and 'restrictions set forth or ` his
application. e
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees:
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit„or cessation.of work for 180 days will subject permit to cancellation.
I certify That I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws gelating to the building
construction, and hereby authorize representatives of this City to enter upon s
th/ above-mentioned property for inspection purposes.
/f' r.
J
)Signature (Owner/Agent) �/ Date 1tl
BUILDINGPERMIT PERMIT# CONTROL#
��►:.�.,,} 4899
DATE., VALUATION$.0 LOT TRACT
JOB SITE
ADDRESS 77-850 ,AVENWAS, 410NUMUNIA
APN
�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
10 ] EL NA,'
`1't: UNGS LAND C T.:t .A:fdING.
73300FIDDI'ANECK LNI
82-910B.EC:hM.AN DPL
P.AANI PES:i{lUf CA, 92260
110RIMAL, CA 92274 -
CF19:1398-0804 Mit 4604
USE OF PERMIT
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PV&'Ritf'1T Sf3e1 AI IN''No WAY iNFIXfF+: ,$— 0F; OUA KAN t -ER IUBSW,11JE N`i•
ISSIJAINCF iW A.'BUILDIN(Ir r-iRj1 IT.
3� f�t����'t'��•�3 Cts. ��` �i3,'�t�'� �t�)t;`fil�rV
0.09
MIMI kv% NOM MARY
O A`it') J T1()ld' MT& t o l -000-423-000 S>A15•�3
Si..if1 tVrA!_, C,0WrMJ.3M`K)N SNP PLAN CHECK
$45.00
L ESS PRI -PAID :FEES
MAR 1
$0.00 ..;
19.97
RECEIPT
DATE
BY
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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
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)
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Case Number
Date Received q-�z-94--
PLANNING & DEVELOPMENT DEPARTMENT
SIGN PERMIT APPLICATION
APPLICATION REQUIREMENTS C1�' l�
Zii.`
A. The following shall be submitted by the Applicant to the Planning &
Development Department at the time of permit application unless otherwise
modified by the .Planning Director:
1. Completed sign application obtained from the City.
2. Appropriate sign plans with number of copies and exhibits as
required in the application. .
3. Appropriate fees as established by Council resolution.
4. Letter of consent or authorization from property owner, or -
lessor, or authorized agent of the building or premises upon
which the sign is to be erected.
B. Plans Required - Information required - the following information
must be shown on the sign plan:
1. Sign elevation drawing indicating overall and
letter/figure/design dimensions, colors, materials, proposed
copy and illumination method.
2. Site plan indicating the location of all main and accessory
signs existing or proposed for the site with dimensions;
color, material, copy and method of illumination indicated for
each.
3. Building elevations with signs depicted (for non -freestanding
signs).
Applicant
Mailing Address
Name of Business /
Type of Business; T__7
Address of Business
FORM.004/CS
f YurrzU
Phone:
Pt-wne:
1