9911-122 (RR)LICENSED CONTRACTOR DECLARATION
I herebyaffirm under penalty of perjurythat I am licensed under provisions of
C6apter•9 (commencing with Section 7000).9f Division 3 of the Business and
Professionals Code, and my License is in.full.force and effect.
License # Lic. Class Exp. Date;
671085 'C39 4151"3 d f Gt
/Date Signature of Contractor W
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that l am exempt from the Contractor's
License Law for the following reason:
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. 704 Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors .to construct the project .(Sec. 7044, Business & Professionals
Code).
() Lam 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 issued. My workers' 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).
() 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
Section 3700 of the Labor
Code, I shall forthwith comply .withh t ops.• -rov�isrons.
pate: s/ 1 - J Applicant'..
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 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
the above-mentioned property for sfposes.
Signature (Owner/Agent) , inspction ''— Date
BUILDING PERMIT PERMIT#
DATE IVW199YALUATION $1,6100,00 LOT TRACT
'JOB SITE., :y,.ifF F'Offf.LNE.13A.�°i�U1110
4
APN ..
ADDRESS'
.OWNER•
CONTRACTOR /DESIGNER /ENGINEER
a UNE HC:P-0.1%po'�"€CIe.��.l~:�J
CCJt":;f�.AN iZt;1C FINI r
5249 AV N.i A i2Ual0s3C
Al'. J -2426 S AND ij:RIVE
3.,A CjtlIVrA. CA'P25 3
LAJ: IDVice CA VZA5
(800) ;>1s-55_52 CY :Fa
USE OF PERMIT
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so M,
TOT AL PERKrY PETS DU M,' 'VOW*
RECEIPT
DATE
By L/ �' %
DATE FINALED
INSPECTOR
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts i
Slab Grade
Return Air {
Steel
Roof Deck —
Combustion Air {
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents {
Fireplace P.L.
Grills [
Fireplace T.O.
Fans & Controls I
Party Wall Insulation
Condensate Lines {
Party Wall Firewall
{
Exterior Lath
Drywall - Int. Lath
i
{
i
�J
Final (
Final I
POOLS -SPAS
BLOCKWAI I APPROVALS
steel I
Set Hacks
Electric Bond {
Footings
Main Drain
Bond Beam
Approval to Cover {
Equipment Location I
Underground Electric t
Underground Plbg. Test f
Final
Gas Piping
PLUMBING APPROVALS
Gas Test i
Electric Final {
Waste Lines
Heater Final {
Water Piping
Plumbing Final i
Plumbing Top Out
Equipment Enclosure {
Shower Pans
O.K. for Finish Plaster [
Sewer Lateral
Pool Cover t
Sewer Connection
Encapsulation l
Gas Piping
t
Gas Test
t
Appliances
{
Final
COMMENTS:
f
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)