9606-044 (SIGN)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perji?f
ry that I am licensed under provisions o
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, andy,.Licens� is in,fu!(,force and effect.
License # , 'Lia Class Exp. Date
5137v M C-45 1 X196-,
DateSignature of Contractor t R
t.
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).
( ) 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 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 IissyednMysofker 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).
(L)
,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 1. should become
subject to the workers' compensation provlslons of Section 3700 of. the Labor
Code, I shall forthwi . comply.with`ihose provisions. 1 '
Date: 6L--1 9 Applicant 1 % , / A %, ti. , !Y
Warning: Failure to'secure Worke Al 111�
s' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. '
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and 'restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under'or pursuant to
any permit issued as a result of this.applicaton agrees to, & shall, indemhify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of#this. City to enter upon
the above-mentioned property Jfor-inspection
, urpo�s s,
�Si nature (Owner/Agent) �1, , r a +�'�` 4 dZf��Date
BUILDING PERMIT , PERM' CONTROL#
3478
-606-044
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 78-992 MY I II
APN
OWNER
CONTRACTOR /DESIGNER /ENGINEER
,�
Ii. QUYA.{AnYSHAGKy;irY$.tGN
.
?8-99-2 HWY 11.1
1540 SAN B ANAAD,.INO
f"A. QUINTA CA. 92253
COVI A CA 91722
(818)915-5694
'
USE OF PERMIT
3.11,1:IUNITNA1ED WAIA, SIGNS z,
CO1+F'i' tAti:'i'A,iOUKT 5,8iit100 U
T UMN,bID COST OF CONST UCT1i40N
1a.EAM1 `1,- 6+'EW SUMMARY
?►tI`tC:l„T,T,A1�1*Cat#iS 10.1-000421-000 5793 00
° t ; CON9 tit MIGN AND f LA. r C
LESS ['R PA1ll # EES
$10,00
f _
�l,
f i,�� NOW.
y y .`�x py�g��ry■ry[• MEN
J "�ry 1 0X996 'i tylA l.,P RR M-1 R e•8�:a.EN Df JE C'1O .
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RECEIPT
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 � Wrap
F.A.U.
Frarriing
Compressor
Insulation
Vents
' Fireplk a 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 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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
,
-
Final
tility 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)
NE00 IL -,L
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�TYPICP�� SIPE vi
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STATIE LICENSE *252976
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ELECTRICAL A6VEFITISiNC,-MAiNTENANCE-LEASES Project
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Scale !Qb-ra Hate
Drawn by Salesman
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APPROVED BY PLANNING & DEVELO NEW DEPARTMENT
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NOTE: this is an original drawing creaked by Academy Signs. a is submitted for your personal use in connection with a project being
planned foryou byAcademy Signs- It is not to be shown toanyor}e outside your organ izslion. Nor is it to be used, reproduced, copied, or
exhibited In any fash4on. Client agrees to pay 25%of I he retail selling pride of this display upon demand thereof if said of iginal design, is
used or -a produced in whole or in part.
CLIENT DATE
15,W WEST SA,N BERNARDINO ROAD, COVINA CA. 91722 (818)915-5694 ' Design,* Approved