9904-126 (RR)LICENSED CONTRACTOR DECLARATION
•1 hereby affirm under penalty of perjury that I am licensed under provisions c
Chapter 9 (commencing with Section 7000) of Division 3 of the Business an
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
4.5[-98 C -19
g Iii/.1s ✓lri�%dc_„li.,
ate / �•� Si nature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor'
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sol
corripensation, will do the work, and the structure is not intended or offered fc
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with license
contractors to' construct the project (Sec. 7044,. Business & Professional
Code). -
( )' I am exempt under Section B&P.C. for this reason
Date • Signature of Owner
WORKER'S COMPENSATION DECLARATION
IJhereby affirm•under penalty of perjury.one of the following declaration:
( ) I have and will maintain a certificate of consent to self -insure for worker:
compensation, as provided for by Section 3700 of the Labor Code, for th
performance of the work for which this permit is issued.
(y" I have and will maintain workers' compensation insurance, as required b
Section 3700 of the Labor Code, for the performance of the work for which thi
permit is issued. My workers' compensation insurance carrier & policy no. arE
Carrier ' Policy No.
` 11.1.ANOVA ,t;0,
°ai'C,098 3682
(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 issuec
I shall not employ any person in any manner so as to become subject to th
workers' compensation laws of California, and agree that if I should becom
subject to the workers' compensation provisions of Section 3700 of the Labc
C de, I shall forthwith'coniply with those provisions.
ate: L/° / c^ ''Applicant /c'', Applicant_:', ,,.'2
Warning: Failure to secure Workers' Compensation coverage s unlawfAan
shall subject an employer to criminal penalties and civil fines up to $100,000, i
addition to the cost of compensation, damages as provided for in Section 370
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and.Safef
fora permit subject to the conditions and restrictions set forth on hi
application. .
1. Each person upon whose behalf this application is made &'each person A,
whose request and for whose benefit work is performed under or pursuant t
any permit issued as a result of this applicaton agrees to, & shall, indemnif
i. & hold harmless the City of La Quinta, its officers, agents and employee:
2. Any permit issued as a result of this application becomes null and void
work is not commenced. within 180 days from date of issuance of suc
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 i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property forinspection p
urposes.
/gnoure (Owner/Agent)/�.�''+•— z'� ' ` Date {'�/<•>>
7 K
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PERMIT#
BUILDING PERMIT
9904-426
DATE A/1. VALUATION S4,500.00 LOT TRACT ,
JOB SITEy (@�
ADDRESS 46-80 CjAMEO PALIAS 11 1� RI1 V Y,
APN
"3-194-004
OWNER
CONTRACTOR/DESIGNER/ENGINEER
DOUG H0N%kRU
Pwe3 "N hl vt\s ugTz 1t07QPJ.NG
s
46800 CAKF O PA.Lt&:1.5 DIZ
45020 ELM.. 91'
LA QUiN1 A CA 92251
INDIO CA 92201
€7Gt1�;3�17 •Sri.`1 0131..4
11-57
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USE OF PERMIT
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EST VNIATE, WCUS T, 4AF COEiSTR 51CTION
4,590.00
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RECEIPT DATE I By / DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
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
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 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
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)