9811-069 (RC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am license&,under provisions of
Chapter 9 (commencing with Section 7000) of Division 3�of ttie Business and
Professionals Code, and my License is in full force and effect.,
"Cicense # Lic. Class r r P. Date
7fiti39� � �f3i7`�1<3
E
Dat �/ ` �� Signature of ContractA_f�r"Q%� ._
9 .�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, 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 contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). j
( ) I am exempt under Section B&P.C. for this reason r
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION i
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
erformance 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.
STATE, F N.ID
(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' compensation provisions° of Section 3700 of the Labor
Code, Idshall forthvul h comply with�ttiose%�,rovisions'.V//'
Date: (�� Applicant r % ''
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 onahis
'application. f,
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 Vold 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 authorie' representive hof this City to enter upon
the above-mentioned property forinspectionpurposes. / t
`Signature (Owner/Agent) ����% Date
BUILDING PERMIT PERMIT#
DATEVALUATION ��LOT TRACT
JOB SITE
ADDRESS 78..297 HWY III
-
4
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JRA&JINIC
D.L. FREEMAN, INC.
'13-5 50 tlX.FSANT)X0 DR. S't`d 200
r2-880 MED WAP-tN DRIVE C43
AtiLIVI DESERT` T` CA ' 92260
PA1,1V DESEM' CA 42^C�i
'
(760.)773-9024 r'131.1i 5390
USE OF PERMIT
i,tLl�i!?RAL WILINNO
VALUATION 150,00UO
COS �1'�� aAa��,� ON
tEnp��.I.�l�A.TED
6j�L54j7��11 �+�IIE.b:�ti7�.1�J.lYRt'G4�llt
PLAN C:tT(;,A:.1" EE, 3 q (,-trf i0-43 .31 K $716.07
.
CO:INST($UCTION Ffp, SH 98 90
MCHANICA3,FEE
S't'RCyhG NI(YrION FEE — C".OMAI 100-000-2414)00 331.�ii
j
LESS :PRE-.PA.10 FE13S
$0.00
RECEIPT
DATE
1, ii) 01 �
BY {ss
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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)
SUPPORT STRUCTURE
22 GA. 6HEFT METAL
LETTER
WAIL FASTENER
STUCCO - 4" LAGS OR TOGGLES
WOOD - #10 SHEET METAL SCREWS
BRICK OR CONCRETE - LAGS AND SHIELDS
�`--- PLEXIGLAS MCC
NEON T U6" G
P K HOUSR40S
U I TRIM CAP
1/1V FLEX CONDLUT
R EMDTE WKXJNT
T RA N S FORNW R IN
APPROVED WTA L
ENICLOSIRE
ILLUMINATED LETTERS
W/P K HOUSINGS
BISHOP GRAPHICS I ACCUPRESS
REORDER NO. A36841
Ljt- APPI,ovFD
dob
Approved By I Scale
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