9907-375 (SFD)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
44Z.
Ip to e► 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:
( .) 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.
( $ 1 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. '
3fC(MAL 11.4`3. CO3 0.P`,t T IV43 17 .
(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 fo the
workers' compensation laws of California, and agree that if I should become
subj t to the workers' compensation provisions of Sectipn 3100 of the Labor
�C fJe, I shall forthwith comply with th so a pro Iv s ons.
te: Applicant X-2az w . �
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 Jees.
IMPORTANT Application is hereby made to the Director of Building and.Safety
fora 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 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
ol
the above-mentioned• property for inspection purplb
,"Signature (Owner/Agerit)1Z':)h, 4 V Date 1 1v i
BUILDING PERMIT PERMIT�9107- 7S
DATE VALUATION aA.bLOT [.� TRACT
td1.,argq
JOB SITE
ADDRESS' 79-3M LIGA.
APN 769-fro&1*14
OWNER
CONTRACTOR / DESIGNER / ENGINEER
DESERT MUMflOr U,CrC;AT'�rst,�;�
:�.�:;�3,�.r>�:d'�I�9.:": iAl:� �"., IN. C;.
51if1PICME, IVAFrE 400,
SPAft.Tt PI.tg3..�, SUM 4W
CA 926 14
aMNE CA. 92614
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USE OF PERMIT !
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FF19AUT PRE SUMMARY
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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. to Wrap
6tf
F.A.U.
Framing
Qjh /'
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 Hacks
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
—7 Cf. grd
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
40,
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final ol ay-
Notice (Gas)
Utility/�� SCJ
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 - -2 Cd
Utility Notice (Perm) =