9809-135 (RR)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. ate
9 b 9a�
/Date Signature of Cont act , r.
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).
( ) 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 self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
Decferrmance 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.
U-:010,114 11114's, Co. 1=1-0.58SM45
(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 t ecome subject to the
workers' compensation laws of California, and agr th?:a tf I -should become
subject e worker
- compensati9tn pr or,,yso�yetion3700 of the Labor
Code, 1 ri
Ith comply witfj't os ro ,is
Date:Applicant jjj H
War' ingo 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
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 if:
& 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 st that the above information is
correct. I agree to comply with -ill City, ano S�ti I ws r atingpto the bu.jlding
construction, and hereby /alltho {repreSe t tines of this City to nter/upo
the above-mentioned p�ro1 rty r. i spe .m poses.
Signature (Owner/Age-tai V Date -
i ;' E
PERMIT# '� CONTROL#
BUILDING PERMIT
yS�l�� 13S
8253 /q q
DATE 11t21198 VALUATION V.33400,00 LOT TRACT 8 2 5 `
Lo Oi
JOB SITE
ADDRESS 77-955 AGO DRk
�,
APN
- -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
IMGFIES
P,(X)FTILC SPEC.'IAIXY
77-955 LAGO DR
40i3 ASTER Dig,
LA QUINTA CA 92,253
PALIVI DUSCs'2 r CA 92211
Q60)341-6073 CM14 1.120
USE OF PERMIT
GURNE.W, BUILDING
aiOVE WOOD SHARE JINSTALL CLAYLT 1030# 3523
RE, 1ROOr' 8,4(0100 'LS
ES IAIATI D C�.:s�x' OF GOMISTRIIC"TION
PERMIT FRE MAINIARV
=100F FTsE
e
_
SPA€�rpoO- NS"l,'I UCTION A ND PLAN CNEC.K
$30.00
USS W -PAID FEES
$0.00
SEP 2 2 1998
RECEIPT
DATE
8Y
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 j�
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 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
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
r
Final
Utility Notice (Perm)