9612-109 (BLCK)LICENSED CONTRACTOR DECLARATION
41 hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7b00) of Division 3 of the gusiness and
Professionals Code, and my'Libense is in full force and effect.
License # Lic. Class Exp. Date
Date 12 IrIA0 Signature of Contract�_r�"Z<
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 property, 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 selMnsure for workers,
compensation, as provided for by Section 3700 of the Labor Code, for the
pprfor5an I ce of the work for which this permit is issued. '
I have and will mainlain,workers'compensation insurance, as required by
on 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & Policy no. are:.
Carrier Policy No.
�317A'11 RANt) -
(This section need not be completed if the permit valuation is for $10OZO 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' compensation provisions of SeptioAn37SO thee Labor
_90
Code wm X
slo
�I I rt �Pi comply hA, se
9se ro
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 3106
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 a
whose request and for whose benefit work is performed under or pursuant I
any permit issued as a result of, this �applicaton agrees tq, & shall,.Indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a resu ' It 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 thiSrapplication and state thatthe-above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby a th i representatives of this City,to enter upon
the above-mentioned prolg onz inispectio
pjauj3osipd.
Signature (OwnertAge
BUILDING PERMIT
PERMIT#
'
CONTROL#
009
4513
DATE VALUATION LOT,
1
TRACT
JOB SITE
ADDRESS 55-333 CHUIiKV 16111-111 IS
7
,.PWNER
CONTRACTOR DESIGNER ENGINEER
11 Q k Bci,� V1
I .1k (JI.011'A CA kYllli�l
LA Ql IIINTA CA
01?5'3
USE OF PERMIT
4:m? L. V O� 614(01�_-jl WALl". -1 Zsi'0,
6 1. ' r. '01 A L L
450 06 LF
ESTIMATED C"ST
OF CONISTWUCTLI.011\1
I 164�1-101WV
1"N.RMYC 1, V& SU 1\1 NIA R V
("IJ14STRII.K.7141N VEI-7 10140)_418_000
SI ITA T(YrAli, CC)NS1R(JCTK)N1
AND PUANICHECK.
PCRMIT
DEG 19 1996
FIFES MJK'N0%V
OF LN ()U'N-TA
^ITY
�ECEIPT
DATE
BY.
DATE FINALED
INSPECTOR
. a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Dr)vall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs i — /_
Electric Bond
Footings Z7,1171M
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Eledric
Underground PIbg. Test
Final
GasPiping
PLUMBING APPROVAL�
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
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)