9610-077 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of periury that I am licensed under provisions of BUILDING PERMIT
Chatter 94commencing with Section 71000) of Division 3 of the Business and DATE VALUATION
'4 1(03116 LOT
Profess&Vss Code, and.my License is in full force and effect.
License # Lic. Class Exp. Date
JOB SITE
ADDRESS
55-776 Clal�K.KY IULLS
Zignature of Contrac rWNER
r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjurythat 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 structur& is not intended or offered for
sale (Sec; 7044i Business & Professionals Code)- USE OF
1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
Larn 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 3700 of the Labor Code, , for the
per)ormance of the work for which this permit is issued.
'V) I have and will maintain workers' compensation insurance, as required by
S�aon 3700 of the Labor Code, . for the performance of the work. for, which this
permit is(il-:'AOOOZ'W..w.or4ort�.4ebmpensation insurance camior7a;,�Mliqpno. are:
Carrier Policy No.
(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 b"me
subject to the workers' compensation provisions of SectionW02dg^
p4labW
Warning: Failure to secure qorkers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to,$1 00,000, 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. 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 representativeA, of this City to -enter upon
the/above-'mentioned property foRy'ns I- I _e s-..
Signature (Owner/Age Date
f
N1 I N[1SX1RFL1A- COV 2,
5011�15 MOWIMN 81AA0OWS REY
LA QUINTA
2il LF. WALL, 0Q0.) 4VTFEN4
9041 -ADW TRACT 4251
N
�GTOR / DESIGNER / ENGINEER
M IN "S L U - I'Al ITI, n, flw,
A44,51NIOUNTAIN SIJAWWS RD
LA Q�UINTA 4CA 922 5�
00 .-;(,,24�
l!"XIIANIATED A_*4'XST OF CONSTRUC110N
1111V110.1"IT
I I 49)0_4 14AX10
17-n 0.)
' 0.2
Ca
W -R -10-M
SUB-TUr,,N_t, CON AND PLA'M CHECK $90.N)
LENS rMt.-PAID FEES, I S6.00
TMAL PERMIT ",ES DUR'NCAV
DATE I BY - I DATE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
S&Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Flreptace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings AX,0010,
Main Drain
Bond Beam
Approval to Cover
Equipment Location
co,
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUM 0-674PPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out.
Equipment Enclosure
Shower Pans
OX for Finish Plaster
—Sewer Lateral
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
Win Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)