9908-120 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury' that I arrilicensed u n6er, provision's of,
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
11130/0"
Vate,;rf ignature of Contra o
—S
OWNER -BUILDER DECLARATJeN
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
.1, 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).
( ) 1, as owner of the property, am exclusively Contracting with licensed
contractors to construct the,project (Sec. 7044,' Business & Professionals
Code). . . .. . I I '. .
I am exempt under S6ction 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 370b 6f the Labor Code, fo . r the
performance of the work for Which this permit is issued.
()4;� 1 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 insbranc - e carrier & policy no. are:
Carrier Policy No.,
S"I"ATIR Rmvyn 44 0 12' .1 -99
(This section need not be completed if the permit valuation. is for $100.00 or less).
I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California and agree,�that if I should become
subject to the workers' compensa ion p�pv[sions of Section 3700 of the Labor
Code, I shall forthwith comply with thoge provisions//
Da'te:*-e/, A-1 -,e 'Applicant X- ;r - _Z &
/ orf y 7 1 %�, f%.J V 'Afv�
/Warning: Failure to secure Workers' Comper�$ation coverage is unlawful and
shall subject an employerto 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. Ekh 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 appl1caton 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 cli�s 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 all6ity, and State laws relating to the'building
construction, and hereby authoriie representatiVes of this City to enter upon
the above- mentioned property fo"Xins'p'ection.purposes.
V gnature (Owner/Agent)
Date
PERMIT#
BUILDING PERMIT
DATE VALUATION '93WR37.1 LPT'
TRACT
JOB SITE
ADDRESS 74446 CE.T'RINO
71Z-1 10-411
OWNER
CONTRACTOR DESIGNER ENGINEER
5.1,370 " BJUNKJDAS, M. 4
'r,1-030 C-MLE WSTAW SIT! 201
LA ("INFA CA �12253
LA. QUIM"A
CA.
9225-4
1760) 77.1 .2 _%'7
fM"
5407
USE OF PERMIT
WNGLU FiWiLY bVhLUNG
MFC.- LOT 1, K AN Vjk� PCRM-1T'0Q�6),R)T INCUADE -OLOCK WjV�L
CUSTOM* CONSITIR40:110IN 11,497.00 3F
T
-5 7. 5 er
C014STREX711aN F -LE 101 -OW -4164"
1q,AK MFOK Ff?-R 10 1-000-439-3113
1X4 C-ffUCA.,TXa, 1-001)420�W,) $ 2�15 8. 0 2
PLUNIB]INO FfF,. 0! - W) 4. 1. 9; - 0 W
RTRCINCZ F0107K)N, f V- i R", K) 10 1 4M. 2 41 .0 010
ORAVIUCY VEE
Af�r M KRUK,; PLACE,, - RESJr 701�W<).115,540
':R It
$UB-TGrAL C0NSoqtT1JCT30N AND PL -AN CYMCK
l
Lf S, r 7 _AID K
$0.0
'POTAL PERM." FW),*FS DUE, NOW
$6451160.61
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
7 ?.,2
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
rw_
Exhaust Fans
OX to Wrap
Framing
CY
F.A.U.
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
C -C/
Final
POOLS -SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
M-a!nDrain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
—C?.g zg:or
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K. for Finish Plaster
Sewer Lateral
zz_- ez)
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)