9710-092 (PAT)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 1� Exp. Date
Date 0'"r r ` 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 isnot 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).
() 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:
(:) Thave 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 Iissued. My workers' "comperisation insurance carrier A policy no. are:
Carrier S`f'ATE FU -N Policy No. 671
BUILDINGPERMIT PERMIT #CONTROLJI -
.Q111
DATE VALUATION '� ° LOT TRACT
6.121
JOB SITE ti.I1-Y tr?Ctk)I�L#L APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / ENGINEER
WI'LLIAN 1, & ANNE KLE COWER
51140 CEALLE I' ALONI A 8-A61 VICKERS 91', SZIrrf3 3o
LA QL11.NT A CA 922.53 SAN Df.tiS: 0 CA 92111
tfi 19]1) 64-1966 01111. 8.59
USE OF PERMIT
(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,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, andi agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code; I shall forthwith comply with0those provisions; wr , r T 3 t4
Date:�h` 21.Gr;Applicant` ` `' ,
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;.
ompensation; damages as provided fo'r 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 g
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 p rposes,
Si nature (Owner/Agent) Date
PO PICH/pAT,O
2Zo.W SF
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P1. AN 04HI"C K F FIs 10 1 - 000-439-3 i ti $3510
COraS't'RUCT40N .FFF !0= 40-419_(" $54 th
e;'rfi(INO MOTION FEW* - Rb ,'s';iL'i 10 f.A W0 -241-t3 D 5.50
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TOTAL AL Pi!:RMI P iIz'E E -S Y)Ul?, NOW
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4P.4 �C ' p
REG T' DATE BY j DATE FINALED JINSPECTOR
$R9 6n ,
$0 00
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
_
Slab Grade VReturn
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
BLOCKWALL A4 ROVALS
POOLS -SPAS'.
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 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
Gas Test
Appliances
Final
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)
COMMENTS: