9807-151 (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
ft rri(174k! ti jj1lit
Date df; /2 `d Signature of Contractor `
OWNER -BUILDER DEC`LA131k ION
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. 70.44, 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.
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.
I" � 11
(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,
shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if Id become
subject -to the workers' compensation pr vi s.of Sectioo 3700 o the Labor
Code, IIT forthwith comply with tho rovi
�O,ons. /
ate:~ :Xa- Applicant
Warning: Failure to secure Workers' Compensation cove ge is unlawful -a i-,,
shall subject an employer to criminal penalties and 6W-fi es 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 Cr
correct. I agree to comply with all City; and State laws relating to the building
construction; and hereby authorize re tatives of this City to enter upon
the above-mentioned p�bpe�rtyfo! ' ection p rposes, f %
!,Signature (Owner/Agent)\`1! , Date •.I
BUILDING PERMIT PERMIT#�D�–���
DATE (�Q� VALUATION j.3_16� 7g) LOT y5 TRACT y 15,1
/
JOB SITE
ADDRESS 4ii- i,5 �,A.SA U.► L WO
APN
6446—i.��-02
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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iw_ LIOX i r l0
')Q95 itANCHO L1.A 66WA Dk.
LA 01)jWI A CA 92753
LA OL iMI A 1::;A. 922- 3
0640771,40411 { RIl?f 7096
USE OF PERMIT
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RECEIPT
DATE
BYa
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
L q
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
(,/,G
F.A.U.
Framing
_
Compressor
InsulationVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
nnmvall . Int I ath
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 1 7 2 Ci QG /2
Final
COMMENTS:
I ELECTRICAL APPROVALS
Temp. Power Pole I -
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final e.
Final 4
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underaround Piba. 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 1 7 2 Ci QG /2
Final
COMMENTS:
I ELECTRICAL APPROVALS
Temp. Power Pole I -
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power