9809-133 (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 p. Date
U_ a3/`)4 C-19 /00
e "(l J i
Date Signature of Contracto
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'
compe sation, as provided for by Section 3700 of the Labor Code, for the
pe rmance 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.
LE -GI N, 11+1.3. CO. WC1_051110015
(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 to become subject to the
workers' compensation laws of Califon , and r e -that -if I should become
subject to the workers' compens do ro isioSection 3700 of -the Labor
Code -,Ps a/forthwith comply I t e- I Ks.
Date:/1 Applica
Warning: Failure to secure or ers' Compensation coverage is unlawful -and
4 shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706'
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person. at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this.applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 'days from date•of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. .
I certify that I have read this application ands a that the above information is 1<
correct. I agree to comply with I City, and tetaws.re`lating to the building
con ction, and hereby autho I repre alive of this,City to enter upon
�Li above mentioned prfop rty i pe purp so es. f �%
Signature (Owner/Age `, Dater
z
PERMIT # CONTROL #
BUILDING PERMIT �PH4iEi-�
�3
DATE y«1195 VALUATION S34,tto.00 LOT. TRACT
8249
JOB SITE
ADDRESS '784)74 LAGO DR
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CURTS Sli.1UMORL
ROOF T.1Lt: SC'.ECf.ALTY
78-074 L.ACTO :DR
740 715 AS"I'P?i1 DIK
LA QUINTA. CA 92253
P.A.[.1✓4 DESERT CA, 02211
(7,30)341-6073 1:M4 .1420
USE OF PERMIT
�� N�'M_L 1�1���.D1•NC�
Ic RVOVE WOOD S%VX ANID `Ci ISTA LL CLAY LT 10804 35133
VALUATION ,S
iN�bi►t".At�.dTED COST OF CSIMrSTY hJ1'a.'dtON
• ft$I
1wk00� &_-F
,F ;1;pp1-000.418-006
ti1t
�
y p SEP 2 2 0
w _
MO AND r Y,AN CHECK
SU's- rOTAL c-QNS'TRUC.'X
'i(1.E?f)
-�` LESS PRE -PAID 17'EES
$0.020
TO M. I RIM F C, FS 1)!3s!,1\�0W
RECEIPT
DTE
'-2i 9.
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
a --r4
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)