0110-216 (PLBG)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,.....- Expr-Date /111
684,5637
Datel d� '� l lad Signature of Contraco ����',' a?1.
OWNER -BUILDER DEC
I hereby affirm under penalty of perjury that I am`eicempt 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.
,_.,-Q—llhave and will maintain workers' compensation insurance, as required by
SectionI700 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 S`T�.'k`lEriEjX14D Policy No. filti!Vd14
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Califof6ia;.and agree that,if+should become
subject to the'workers' compenpation provisions of Secfion 3700 of the' Labor
Code, I shall fortwith comply With,those provisions. .,
Date: JI/I$,? .�`> .,.t" Applicant'
Warning: Failure to secure Workers' Compensation .c'overage isnu lawful and
shall subject an employer to criminal penalfie 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 inspection purposes..
/
Date
Signature (Owner/Aged _l
BUILDING PERMIT PERMIT#
jjJ
DATE J ,Jt VALUATION LOT ��'���' TRACT
I I2 r43
JOB SITE
ADDRESS �Sa.. twxV. r
APN
• � .;� .
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1+r1R.. & W0. LOUIS WOMB
.L'1E?tWER F.%i ATM, INO & COME .
78-5€>Ci 1%OT"i ` ''C: &I J RM,
4575 Z C AMNO PARC)WA
LADamm l'9. A 92253
PALM 1133t� G8 C A 92264
t`760432200 CHIA 3371?
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t � 1)71) 15,4;A
USE OF
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71
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7
CWV' , � QUARtRTa }
VALUATION 2,000.00 1,&'*
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1013 'PRE -PAID iMMS
$Q. CKII
TOTAL MMU F, A"W5 DUE NOW
VWX*
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RECEIPT
DATER 7 By
DATE A
IN ECTOR
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
0. 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 Plbgl 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
C
r Lateral Pool Cover
Aewer Connection ZJ Encapsulation
Gas Piping
Gas Test
Appliances
/a 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
Final
Utility Notice (Perm)