9802-052 (SATT)LICENSED CONTRACTOR. DECLARATION
CO I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N co Professionals Code, and my License'is in full force and effect.
p :5 M License # Lic. Class Exp. Dat9--.-,,11
W r
is `?r:iid39
cZ Date K- Signature of Contractor, 1
co 0 ~ /
J U C) OWNER -BUILDER DECLARATION
LU W ~ I hereby affirm under penalty of perjury that 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).
c") () I am exempt under Section B&P.C. for this reason
NDate. Signature of Owner
rn
d Z WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
A FQ- p O 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
nJ Q performance of the work for which this permit is issued.
Q U (. ) I have and will maintain workers' compensation insurance, as required by
jSection 3700 of the Labor Code, for the performance of the work for which this
U
L rn Fa- permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier Policy No.
GD 5 S'L'ALr,. 1,1.%111.3 131, 110115917
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 subjgct-Jo the
workers' compensation laws of California; and agree that if I should be•ome
Subject to tK6 workers' compensation provisions of, Seption ,3700 of the,Labor
Code, (Is�iall forfh Ith comply with those provist�ions. 1
Date: L' f�t Applicant ' J
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
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_ authorize repl@sen�tatives of this City to enter upon
the above-mentioned propertyforinspect on,,purposi
Signature (Owner/Agent)-- f Date
BUILDING PERMIT PERMI78 CONTROL#
'i9d0Y;?••4l51'
DATE VALUATION LOT TRACT 89
JOB SITE
ADDRESS 413- C.:A Ali T A ..1 R1N' !:
APN Ii�S13-�:+vrl ��fD.Y
OWNEER�
I DESIGNER/ ENGINEER
r JCONTRACTOR
i.tI).L .�t;: t.CJ.iA�,1
1
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LA 4,)U1-NH'A CA 92 2:0
I.A.t„1)TN`I'A C1 A ;
f7CMfi 711-1941
USE OF PERMIT
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSF'PECTIOI'J f?EC •RDD
OPERATION
DATE
If�SPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
RfdECHAMCAL APPROVALS
Set Backs
1
Underground Ducts
Forms& Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
-
Exhaust Fans
O.K to Wrap
7�3yf (,�
F.A.U.
Framing
gra -9
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 172 -7/s7
Final
BLOCG(WALL APPROVALS
POOLS e SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMMNG APPROVALS
Gas Test
Electric Final
Waste Lines
2-
_
//f
Heater Final
Water Piping
Plumbing Final
'Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
"
Appliances
Final
Final 2- _
Utility Notice (Gas) /2-15 g dli�
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lovr Voltage Wiring
FMures
Main Service
Sub Panels
Exterior Receptacles _
G.F.I.•
Smoke Detectors
Temp. Use of Power
F"sna9 %-
l#!t'y Notice (Perm)