9604-148 (PLBG)LICENSED CONTRACTOR DECLARATION
U) • d hereby affirm under penalty of perjury that I am licensed under provisions of
x Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel w Professionals Code, and my License is in full force and effect.
O Z) co License # Lic. Class Exp. Date
(:3 LO oi4107
r- CC: r1_ %
ZO n + / vDate r Signature of Contractor
T
U °� OWNER -BUILDER DECLARATION
HLULU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
Q WORKER'S COMPENSATION DECLARATION
CL
2 Z I hereby affirm under penalty of perjury one of the following declarations:
1-2 O () 1 have and will maintain a certificate of consent to self -insure for workers'
LI �= compensation, as provided for by Section 3700 of the Labor Code, for the
D J Q performance of the work for which this permit is issued.
Q V gyp" I have and will maintain workers' compensation insurance, as required by
j C) Q Section 3700 of the Labor Code, for the performance of the work for which this
i permit is<i'sstEi6a,WM `workers' compensation insurance cad i'_6`0 •' 864 no. are:
? Z Carrier Policy No.
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(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
�C de, I shall ort ith comply with those ovls ns.
te: s C 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 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 relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
3lgnature (Owner/Agent) 1, _ f Date
DATE �, PILDING LUATION $1,4X6.00 LOT
PERMIT # CONTROL #
3222
TRACT
JO
DRES -• ' y3��}ti�:►��,VKiNi0,iCAK�iN7A IAPN 774 -045 -Gid,
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
LA QUINTA CA 02353
USE OF PERMIT
PLUMBING
SEWER "3NW-r_ /S0yF1 AHANI)ON
a sEr:Dt:rCKSON C0NS'rRL1(:f Q'N
x379 KIELE-Y R.D.
C INE DRAL (ATY CA 9211.12
(619)32R- 174 7 CRU4 IN
F'STI;tiMXFED COST' OF C_t)ti.TI-RUCI-ION 1,486.1114i
Pt1Uh1l11fN<1% FEE -- SEWElt 101-000-419-060 S3t).(14
SUB -TOTAL CONSMUCrION AND PLAN CHECK- $30.00
LESS 11 E3 -PAID 1111U."s I S000
T(TrAl, PERMIT F EWN DILIE NOW 1 S30.00
RECEIPT I DATE I BY I DATE FINALED I 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 Limes
Party Wall Firewall
Exterior lath
Qrnvall - Int. Lath
Final
Final
i
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
Heater Final
Water Piping
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Spier Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
UtRy 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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Pu P G SERVICE
2502 Morongo Trail
Palm Springs, CA 92264
(619)327-8859
NO 90246
SOLD/TO
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PAYMENT. DUE UPON RECEIPT