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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of p
,�.rjury 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. I , .
License # Lic. Class Exp. Date
- 396698 C12 C14 C42
Pa e /1-3 -7 ?Signature of C�ntra�tor n.
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 -i
( ) 1, 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
performance of the work for which this permit is issued.
( X ) 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:
Cartier Policy No.
STKfE r 12
� MO.) 416-7 W,98
(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'.,,co'Fnpensation laws of California, and agree that if I should become
subje
.,pt/to the workers' compensation provisions of Section 3700 of the Labor
Cc It ose P . .
,Oe, I shall forthwith comply with h ions.
el or Applicant ki P
D6te: — , g, Y -VI n /,, 9 -4
11 pV ----; ZZ , 7 - L. -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalfies 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. ll�gree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
11
'7the bove-mentioned property,,for inspection purposes
I J ate
gnature (Ownier/Agent) P , I D.
T7
PERMIT# �
BUILDING PERMIT
DATE 061031199VALUATION $6,000.(06 LOT TRACT
JOB SITE
ADDRESS -79-045 (AITILE, CADIZ -
APN
769-103-007
OWNER s
CONTRACTOR / DESIGNER ENGINEER
CUNKFUIS 11C
1MVELAtIff.) COMMIUC110N
78045 CALLE CADIZ
50305 H,"Iry I I I
LAQUINTA CA 92253
COACHELLA CA 914256
(100)398-5544 r1BUt 31
USE OF PERMIT
ABANDON S13PUC, C014MCT'r0 EXISTINO SEWER
VALUATIM 6,0000.00 LS
E8'!1*MM'TE0 C03711r OFCONST
61000-00
Pli4l,milf FEW, SUISMINRY
PLUNWING V.m __ Mr-twb3L 101-000-4t9_000
��TJGIT_)N AND PIAN C'MECK
$30.00
LES -S' PRF -PAID FTES
PA ID
$0,00
1*0TA1, PURN111F.1'FEWS DUCINOW
JUN 0 3 19aa
%04
I TY OF LA Q U HN'T.4
RECEIPT
1.
DATE
1 M
DATE FINALED
JINSPECTOR
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
SetBacks
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
I I
------- ---
Final
Final
BLOCKWALL
APPROVALS
POOLS -SPAS
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
Final
Utility Notice (Gas)
ELECTRICAL
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures;
Main Service
Sub Panels
E)derlor Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
UU14 Notice (Perm)
APPROVALS
COMMENTS: