9911-174 (SPIN)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
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:
(�6 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)'
(�Arn exempt under Section B&P.C. ff r this reaso
Zate ��" Signature of Owner — H9
i
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.
(This section need not be completed if the permit valuation is for $100:00 or less). t
O 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
workerfcompensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 370 • of the Labor
CAB, I shall forthwith comply wit those provisio - s./��'"�
Vuate: S"��' J Applicanto��� -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer.to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
, of'the Labor Code, interest and attorney's fees.;
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on . his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work -is performed under or.pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any.permit issued.as a result of this application becomes null and void if
work is not commenced within .180 clays from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct( I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
thelabove-mentioned property for inspecttiiioon, purposes
Signature (Owner/Agent Y/./� '1 U � /[' � e 11-2V49
9
BUILDING PERMIT PERMIT#
DATE 1112411 99VALUATION -SAW LOT TRACT
JOB SITE 36450 *FGAk BOATjl.&VAR.ia
APN ti
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
'.
K-KR.4dL:k^a0ful
vV\K COMP
4-9-199 EISENHOWER DIt
LA, !}'U N A. C A 92253
USE OF PERMIT
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LESS PRE- PAUYFEE S
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'91`D'$At VERMIT F.EES DUE NOW
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6: 1,
RECEIPT
DATE
By/ y
DATE FINALED
INSPECTOR
4�
INSPECTION RECORD
OPERATION
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 I
F.A.U.
Framing I
Compressor
Insulation I
Vents
Fireplace P.L. t
Grills
Fireplace T.O. )
Fans & Controls
Party Wall Insulation I
Condensate Lines
Party Wall Firewall }
Exterior Lath I
Drywall - Int. Lath i
1
1
1 _
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs I
Electric Bond
Footings I
Main Drain
Bond Beam }
Approval to Cover
Equipment Location
1
Underground Electric
I
Underground Plbg. Test
Final !
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines !
Heater Final
Water Piping j
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral }
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
i
}
I
Final I
Utility Notice (Gas) }
ELECTRICAL APPROVALS
Temp. Power Pole }
Underground Conduit
Rough Wiring }
Low Voltage Wiring ;
Fixtures i
Main Service
Sub Panels
Exterior Receptacles)
G.F.I. I
Smoke Detectors
Temp. Use of Power 1
Final }
Utility Notice (Perm) 1
COMMENTS: