9908-123 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions 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
'7430211 NiloiI9�
D �te_�tf/ "I Signature of Contractor A4
OWNER -BUILDER DECLARATION
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 pcop6rty,.am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
I am exempt under Section 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 370 0 of the Labor Code', for the
performance of the work fo( which this p�raiit is issued. I
(J I have, and will maintain 'workers' compensation insurance, as required b�
Section 3700 of the Labor Code, -for the performance of the work for which this
permit is issued. My workers' 'compensation i , Insurance carrier & policy no. are:
Carrier Policy No.
Vb
STATE t LX
(This section need not be completed if.the permit valuation is for $100.00 or. less).
I certify that in the performance of th , e work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to th6
workers' compensation laws of CalifpfAi - d ag-ree that if I should become
ia, an
subject.to the workers' compehsa io " prcvis�,Kso�16f Section 3700 of the Labor
Code] shall forthwith complywith eh6ps`;e provis ors.
D&:' A ilic
Warning: Failure tn secure Workers' Com ensation 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
applicatio ' n.
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/Eity, and State laws relating to the building
construction, and hereby authop-9 representatti'ves of this City to en I ter upon
the above-mentioned property f (ins'peiction'pu"'rposes.
I'll I
k.si5nature (Owner...ge Date
7
PERMIT#
BUILDING PERMIT
9*13423
DATE(-- VALUATION I LOT
1L. TRACT
JOB SITE 79-434 CCURNO
ADDRESS
OWNER
CONTRACTOR DESIGNER / ENGINEER
CIM1,11,111S. DE -1. r-10TIMAE"NIT 111k,
1. A !�%rf N ,-it *,I NAAS AV, V
51 -376 AV, BEIRMU1,1,16" -11,,_ i
-OR0 CALLE �rrhr_kq KM
20 1 -
LA QWTVA CA ',42233
LA QUINTA
CA
922-53
(76MT71 -2567
CATAI
5407
USE OF PERMIT
V.D. LOT 19, PLAN 30.18, - PERA41T )AXIS NOT DWIAUC BLOC WALL
").40 *F'
OAR AMYCARPOWf 903.00 SF
T
EST INLAXED IMST OF CON113,11 tM-310IN
.1J
01M, `9
U7,0r. .A
PERW)f VEX, SUMNISLARY
CONSTRUMON FtE
V 1, A N * CKIY, K TT 9 1, 9
3
,
1
PLkJMbFN('T FEES 10i -00041449A
r
01
AI(T IN i1TJjKJC PLACES $667.36
FIR
UP -1 MALOON, ,LlCrr10NAWT)P(,AN CHN,
0,1! 17 2
1,
TIESS PRE -PAID FEES
$0.190
TO'.IrAL PERMIT FEES 013r..)NIomi
$6,112.22
RECEIPT
DATE
BY
E FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I
DATE I
INSPECTOR
OPERATION
I DATE
I 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
ci-)
F.A.U.
Framing
Compressor
Insulation
:R_ f,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
ev Ager
Final
Final
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 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
COMMENTS:
Final
Llfility 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)