9611-059 (AR)M
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of per-Jury,that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Codej and my License is in full force.a"ndi e effect. I -
License # f Lic. Class Exp. DAte
Date
Signature of Contrac r �v., lip
V I % I
OWNER -BUILDER DECLARATION
J hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 f& workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
K) 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.
ST ATE Mr,"M -.71.09594
(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 is permit is issued,
I shall not employpny person in any man er so as to b(corn ubject to the
sI`
if
workers' cdiTipensation laws of C-1.1-iiiia ' rand agree th t I llshould/become
isiond f S On 3700 of/
subject to the wofkers' compensation prov he Labor
I- f:
V�ode,� �shallofprthwith comply with th?s provisions
ate: Applicant—
Warning: Failure to secure Workers' Compensation coverage is Onlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000� in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Saifet y
for a permit subject to the conditions and restrictions set forth' on�,his
application. . ?
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant t6
any permit issued as a result of this applicaton agrees to, & shall, indemn-ify i
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subjeqVpermit to cancellation.
I certify that I have read this ap
correct. I agree to comply with
construction, and hereby authi
\7 th /above-mentioned property , I
Signature (Owne...
and sta 6 h t1th � Wove informalion is
and Sletla2s r,91 ting to the bbilding
se I I ives of this City to ente upon/
.t,6n�lr
�poses.
T#
BUILDINGPERMIT PERMI CONTROL#
DATE VALUATION LOTI TRACT "A459
JOB SITE
ADDRESS 7!)-014) CARKEL, CIU0.1111
OWNER
CONTRAC�OR DESIGNER ENGINEER
vauzs cat;,,s,,nwmn,,m
79295 RANC-110 tA QUIN rA. DR,
LA QUINVA CA 92251
LA, QVINTA 'CA 9.2253
(619)771-1,941 CUlff 2996
USE OF PERMIT
RESIDENII A!, ADMI'lON
IV3D td() F. 1_0 OR (Wf ROOM ($ 1 4,428A VAILTNf 10 N) AKIO 270
S, F OF C0 V,1�4RED PORCH (SI, 591.0 VA1,W%X ION),
RMODIa. - -CUSTOM I J:AM.00 S.F.
1j',()R(3"1 Xf 10 270.0 sill
.11—AN CIIECK F11E $111.15
rIONST111 X'7CION F M- 101-000-418-000 MIX911
U, 101 -OW -4214)00
VLECTIUCAL'V01'
F!Yi, 225-000-4411342 S26 L63
SUM-TOVA!, C"NM31"RUCTION AND PLAN CHECK.
&%Ifl)
CITY OF L-A QUINTA -
10TAL PERMIT F'19R,8 DUC-NOW
DEC 19 1goo
FINANCE DPP -r J
"RECEIPT
UAT-ff'
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION _F
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
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
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I I
Underground PIbg. Test
Final I I
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
G" 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)