9902-089 (RER)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
5.566,93. x3 2d2 -W99
Date Signature of Contractor
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).
( ) I, as owner of the property, am exclusively cont am8 ' g with ;licensed
contractors to construct the project (Sec. 7044; Business•&`Professionals
Code).,
(
""'a m exempt under Section B&P: . forthise"asij
Date Signature of Owner
WORKER'S COMPENSATION DECLARA ON
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
performance of the work for which this permit is issued.
( ) I 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 insurance carrier & policy no. 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 performanV thezo�v,rk= or which this permit is issued,
I shall not employ any person` iri arly�a�ne so s to become subject to the
workers'' compensation laws of Calif friia;,and a • ree• that if I should become
q �._...
subject to the wpp`rkers' compensatioh provlsip`rf Section 3700 of the Labor
Code, I s a!I for4)awith comply�witbiM Be r6v'slons.
Applicants Be
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the. Labor Code, interest and attorney's fees.,
IMPORTANT Application is hereby made to the Director of Building and Safety
for -,a• permit, subject to ;the- conditions and restrictions set forth on his
application.,
1. Each person upon whose behalf this application is made & each person at
j whose request -and for whose benefit work_ is performed under or pursuant to
•any permit issued as a result of this applicaton agrees to, & shall, indemnify
4&, hold harmless the City of La Quinta, its officers, agents and employees.
2. Any, permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date- of issuance of such
permit,. or'cessation of work for 180 days will subject permit to cancellation.
I certify that l have read this application and state that the above information is
correct: ,l• agree to comply with all City, apd State-ldws relating to the building
construction, and hereby authorize -•re resentatives of this City to enter upon
the above-meritioned property f \r insp��tlon.purposes.
r
VSig ture .(Owner/Agent)!j -2
Date �7
BUILDING PERMIT PERMIT#
+3�1597.wU:s'�
DATE 2/16199 VALUATION S'I,()I)0JJ0 LOT TRACT
JOB SITE
ADDRESS 46-800HIGH1,Af' D i► ALNIN ,DRINTi,
APN 3✓�9-A448.1,
0
OWNER
CONTRACTORD]E,S�IIGNEER(]/ ENG1144EER
y p `{j(+�y
j/
( ] �/ N]'j {N
22811 GOLDEN LOCUST 1UR
20056 ESQUILINE AV8NU1
CORONTA CA. 91719
W'A'LNU! Cly. 91789
(!309)595-0073 5255
USE OF
(PERMIT
31.`i.1J.�„��1. •�.F.Li tld .dLl:/f:�l.y.�l.�.41
.
REMOVE AND r• L%1URE.% F1WJ ,ifC4',q
ANDJR.001UN0.
0
_ ,4!. •.i..!!►'AA_. .a y/ COST vA� 9„-4iTi'3 h ORU�. �tl G1N
t
PERMIT FEE SUiMNIAMV
C."•0N$•f,•42t;ir3'10WFEE '101-000-419-000
�T
t,
LESS PU-PA)BIFTES
$0.00
Ti" TAI., NOW
3:�5.t1Qi
U d
EC IPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
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
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
Drywall - Int. Lath
Final '
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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 ti
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
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)
COMMENTS: