9802-046 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 co Professionals Code, and my License is in full force and effect.
C :5 ch License # Lic. Class �.^- p. Date
r- X
Z r- Dated + Signature of Contradzi, 1 i�
p
6
J U 0 OWNER -BUILDER DECLARATION
W LUU I hereby affirm under penalty of perjurythat I am exempt from the Contractor's
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).
cr) O I am exempt under Section , B&P.C. for this reason
O N Date. Signature of Owner
rn
a Q WORKER'S COMPENSATION DECLARATION
� 1 hereby affirm under penalty of perjury one of the following declarations:
A H, p () 1 have and will maintain a certificate of consent to.self-insure for workers'
K W compensation; as provided for by Section 3700 of the Labor Code, for the
n_ Q performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
j U Q Section 3700 of the Labor Code, for the performance of the work for which this
L LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carver Policy No.
ob :50 . ST.'t 'c E'1.ff� I;t 1.37109997
J (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 sub' ct to the
workers' compensation laws of Californ%,and agree that if 1'�should)become
3 subject to th`Wonkers' compensation prov Bions of Sectiori' 3700 of the Labor
Code, Q fl ! %�' ith comply with thos�pr visions.
Date: Applicant
Warning: Failure to secure Workers' Compensatlon'coverage is unlawful an�
shall subject an employer to criminal penalties and civil fines up to $100;000,/fn
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 applicator agrees to, & shall, Indemnity
& 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 Citf and State laws relating to the building
construction, and hereby authorize � presentatives of this City to enter upon
the above-mentioned property for iris ction purposes.
/Signature (Owner/Agent) Date r-�
BUILDING PERMIT PERMIT# CONTROL#
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DATE 1 VALUATION �.LOT TRACT6817
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01 IZ�
JOB SITE �-D
ADDRESS 4&0 (51 CiViF A DRIVE,
APN
64! -380--003
OWNER
CONTRACTOR ! DESIGNER / ENGINEER
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1.At:�tf1'i'!'tl (-.*A 9:125-t
LAfN I.NTA. CA 922`5.1
USE OF PERMIT
UNi l S_,, CAM f A Nt, A146. 0, Ali Gb_,' `K PORT f ON OV kt,E �R i ,
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2.0.5 00
APR 0 8 1998
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OF ?� a.��R�Tft
PERMIT FEE SUMMARY
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i,7R+'V)CN(71 FEL 101-000-423.,000
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RECEIPT
DATE
BY '
DATE FINALED
INSPECTOR
�PECTION F'�ECnr�D
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
B ULLDWO
APPROVALS
. MECHAMCAL APPROVALS
Set Backs
3 -17- G
Underground Ducts
Forms & Footings
/ GlG
Ducts
Slab Grade
;;2-(=q
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
- -Q
F.A.U. _
Framing
-
Compressor
Insulation
-,;2-2 9 /
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
SLOCKWALlL 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
PLMMENG APPROVALS
Gas Test
Electric Final
Waste Lines
j -
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
7 Z
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
CELLECYMCALL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fhdures
Main Service
Sub Panes
Exterior Receptacles
G.F.1,
Smoke Detectors
Temp. Use of Power
G6ni0
Utility Noti:,e (Perm) �j"-
COMi Uri EM M