9802-047 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
C :) co License* Lic. Class Exp. Date
Cy W r 4J f +'tl Lir. .� S �
Z Date C/�. 'ff` Signature of Contractor /
CD 0 � �� � //
J1.-
0 OWNER -BUILDER DECLARATION ~�-�
HW
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
W 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).
M() I am exempt under SectionUl) B&P.C. for this reason
NDate Signature of Owner
Orn
Q WORKER'S COMPENSATION DECLARATION
Z
I hereby affirm under penalty of perjury one of the following declarations:
FQ- O O 1 have and will maintain a certificate of consent to self -insure forworkers'
K W Y compensation, as provided for by Section 3700 of the Labor Code, for the
�
Q performance of the work for which this permit is issued.
Q () () I have and will maintain workers' compensation insurance, as required by
LQ Section 3700 of the Labor Code, for the performance of the work for which this
1 rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
? z Carver Policy No.
Cb O TAlT, F v'rvJ &17105,97
g (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 beppme.,subject to the
workers' compensation laws of California, and agree,.th-a if I should become
3 subject to t�h6 w�prkers' compensation pr Isionsrof Section 370dof the Labor
Code, I shall,forthwith comply with those provisions.
Date: �'��• Applicant (�
Warning: Failure to secure Workers"•Corraperation coverage is_unlavkf . nd
shall subject an employer to criminal penalties and civil fines up -to $100,000, 1
addition to the cost of compensation, damages as provided for in Section 3706E
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
k* 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 authot+�e presentatives of this City to enter upon
the above-mentioned property for' pection purposes.
ySignature (Owner/Agent)." / _ '- Date
CONTROL#
BUILDING PERMIT PERMIT�6X[)L
1-047
DATE VALUATIONS164.91q "0 LOT TRACT 6818
L. -n
JOB SITE 1
ADDRESS 4x4.035 CA.�VI1 A Dlii�,n i T
APN billt tf�1.5
OWNER
CONTRACTOR / DESIGNER / ENGINE�t••ERi
7y 4 1 A
``1 J,r 11.*',
1.'.ti:ls 11.*', V1 IX)!�,l,U.-N'.
.�7. %�A 11114 S �,t.�i� )i'iii_�C 1(•)i:
P.(-)- BUX 1.7116
792:95 'rrtliiv(.Ei03.A 01.ilNTA i:sit
LA, i'�3131A1'1:�, C.'A 12'2WI
LA iNJI T`A CIA 92"153
USE OF PERMIT
SPA
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ts'U'h:'f'f R1)C:'T10N FES 101-000-4184") b2��1.t)ij
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NU4_1 I ANIC:AL FLJ_ 101-00('1421-000
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RECEIPT
DATE
BY /
DATEFINALED
INSPECTOR
MSPEC T 00 1 RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANOCAL APPROVALS
Set Backs
Underground Ducts
Fonns & Footings
5pf(i
Ducts
Slab Grade
CRL6!
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
- d'- .
F.A.U.
Framing
Compressor
Insulation
2 .
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 —
B9aOCKWALL APPROVALS
POOLL S _ SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
3
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 - S
Utility Notice (Gas)
EL ECTMCAL 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
FiroaO � -
Utitity Notice (Perm) �Z
COMMENTS:
NTS: