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9805-006 (BLCK)
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 692059 C-53 713`1/98 Date Signature of Contractor 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, 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). rl Vj am exempt under Section B&P.Cffolf thivreasoni �4 ✓ ; �e� Signature of Owner i A . P,..e;' / WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the ffOlt wing 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. CAL COMP-ILW 6993136509 (Thi`s/ section need not be completed if the permit valuation is for $100.00 or less). ( 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 California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code," I shall forthwith comply with those provisions. i l f � Date: jApplicani ✓ / i A .+� Warning: Failure to secure Workers' Compensation coverageeds' ur wful and shall subject an employer to criminal penalties and civil fines?up Y,1$100,000, in addition to the cost of compensation, damages as provided fo�,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 purpdses. Signature (Owner/Agent) ��'' rl Date) PERMIT PERMIT# BUILDING I�I CONTROL# DATE VALUATION :, LOT 9805 i1411S TRACT 7616 it 1198 $1,363.95 JOB SITE - APN ' ADDRESS 7&635 SAGUAkO OWNER CONTRACTOR / DESIGNER / ENGINEER f BRADON & CARLA J :(,R.0FF OWNER BUILDER ' '78635 SAIGUAR0 RD z; LA QIJINTA CA 92253 CBLf1 1844 USE OF PERMIT ] s 9 fit JI .'AN( 63LP rir S'CITY STANDARD GARDFNBL,OCK WALL 5 FT, WALL 63.00 LF .ESTIMATED MST OF Cf3NS1TRUCTION 1,364.95 PERMIT FEE SUMMARY CONSTRUCTION FEE 101-000-+115-000 , � $33.00 Li MA 01 1998 .'%«y © LA QUTA TTA 3 SUB -TOTAL CONSTRUCTION SAND .PLAN CHECK $33.00 LESS PRE -PAID F13E.S $0.00 TOTAL PERMIT FEES DUE NON $33.013 RECEIPT DATE ` BY DATE FINALED INSPECTOR 4 / tf��(� " ( 'r , , INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs I Underground Ducts Forms & Footings I Ducts Slab Grade I Return Air Steel Combustion Air Roof Deck I Exhaust Fans O.K. to Wrap l F.A.U. Framing 1 Compressor Insulation 1 Vents Fireplace P.L. } - Grills Fireplace T.O. I Fans & Controls Party Wall Insulation I Condensate Lines Party Wall Firewall I Exterior Lath 1 Drywall - Int. Lath 1 I Final Final BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs I Electric Bond Footings / Main Drain Bond Beam Approval to Cover I Equipment Location I Underground Electric Underground Plbg. Test Final p Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines f Heater Final Water Piping I Plumbing Final Plumbing Top Out I Equipment Enclosure Shower Pans ± O.K. for Finish Plaster Sewer Lateral ] Pool Cover Sewer Connection Encapsulation Gas Piping ] Gas Test I Appliances +, 1 Final I Final Utility Notice (Gas) ELECTRICAL APPROVALS t Temp. Power Pole I Underground Conduit? Rough Wiring 1 Low Voltage Wiring I Fixtures Main Service i Sub Panels i Exterior Receptacles ! G. F.I. Smoke Detectors Temp. Use of Power { 1. I e r Final Uti1'dy Notice (Perm) ', COMMENTS: •