PLBG (9712-062)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 fulIfforc Viandeffect.
License # Lic. ClaExp. Date
/Date / �ignature of Contractor`"'"''Y�
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 Policy No.
N111) t"ENIX1RY INS. ( NOIOR-21-93
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of fie work for which this permit is issued,
I shall not employ any person in anycanner so as to become subject to the
workers' compensation laws of Calif )ia, and agree.that if I should become
subject to the workers' compensate prove ons of Section 37� 0 Labor
Code,shall forthw, th comply with t oSe pr visions ___
Date: yz�r� ` Applicant
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 1,80 days will subject permit to cancellation.
I certify that I have read this aF
correct. I agree to comply with
construction, and hereby auth/
the above-mentioned Drovertvl'
Signature (Owner/Agent)
ication and state that the above information is
ICity, and State laws relating to the building 1
ze representatiyes of this City to enter upon
inspection purposes.._
-'`Date
BUILDING PERMIT PERMIT# CONTROL#
I�
DATE VALUATION LOT 9717-062 TRACT 6473 Q 7 _{
-fir
[ �+
12/12/975250.011 _
JOB SITE
APN
ADDRESS
81-"51NOIT'Ni rAIN VIEW LN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
DEB DEGAN
A R N1 CoNSTRUCTION
81-905 NIOUNTAIN VIEW LN
78-070 CAUY CADIZ
LA QUINTA CA 92253
LA QUINTA CA +12253
( 70))564-1832 CRL14 626
USE OF PERMIT
2.5if OAS LINT FOR BBQ K46 DIU.IJX A0AftL457:►001
VALUA'T'ION 250.00 :LS
E.i1 imATEU (.`COST 0I+ C.'ONSl7 ucrION
25R.U11
PERMIT FEE SUM11LVRY
I'LUNIBING FEL I0I-clao-•u 9-oUo sis.nn
s
C � SI I3-IMAL CONS'I'T LICTION AND PLAN CHECK
LESS PRE-PAIDI'll-ES
so.00
DEC 12 1997
TOTAI. PERMIT FEES DUE NOW
S18.00
ITY OF LA QU NTA
+
RECEIPT
DATE
BY
`1 a
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
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
Utility Notice (Perm)
COMMENTS: