9904-206 (TT)LICENSED CONTRACTOR DECLARATION
':,Thereby affirm under penalty of`perjury that am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, •and my License is in'full force and effect.
License # Lic. Class Exp. Date
CY .,r),W12 13 05i3IJ'!(R
ti � �
CZate �- _L_ Signature of Contractor
0 n
J`V OWNER -BUILDER DECLARATION
�
W
. W r` I hereby -affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason:
Z (;) 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 oroffered '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).
� O I'am exempt under Section B&RC. for this reason
Date Signature of Owner
Orn
U; Q
WORKER'S COMPENSATION DECLARATION
-3t Js; 1 hereby affirm ,under penalty of perjury one ,of the following declarations:
' O.Q o (:) I,have and will maintain a certificate of consentto self -insure for workers'
< OO
X 111 — compensation, as provided. for by Section 3700 _ of the Labor Code, for the
0• J,Q. performance of the work for which this permit is issued.-
(� ( ) I have and will maintain workers' compensation insurance, as required by
0 U ,a Se6-on 3700 of the Labor Code, for the performance of the work for which this
fl€H permit is .issued. My workers' compensation insurance carrier 8. policy no. are:
,Z. Carrier n Policy No.
A•Ml`:r1Y1
„Q (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' mpensation laws of California, and agree that if I' should become
subje to the workers' compensation provisions of Section 3700 of, 'i6e .Labor
C e, I shall forthwith comply with those pr�,vis, ns.;
ate: Applicant ��✓` -ate
T7__
A -" -
Warning: Failure to secure Workers' Compensation coverage is .unlawful and
shall subject anemployerto 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 pursue to
any permit issued as a result•of this applicaton agrees to; & shall, indem�fy
&. 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
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.
1 certify that.I have read; this application and state that the above information is
•1111 correct/l agree to comply with all City, and State laws relating to the building
constfuction, and hereby authorize representatives of this City to enter upon
therabove-mentioned property for inspection pu-rposes..
ignature: (Owner/Agent) c �'-'�r Dat&: �k 11�
f..i
PERMIT #
BUILDING PERMIT
DATE �laiz,�, t �) VALUATION S1.400.00 LOT TRACT
JOB SITE
ADDRESS 32470 D1,16, G'A O 0141VSi:
APN
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
r n �t <j tl cr �IAI`j
T'}3: irr��rr (,(- l ri i le -vi h j Havrr
s •mal•... fa..
79 SHORcELIN`E CIRCLE
4?iT20 RALN711D C:AH1'ON ROAD
INCI;,INE. VILLAGE b1V 89-11150
PALM I3F. .►srt'I CA W2.2,6)
(760)77;3-4764 CMA 1450
USE OF PERMIT
iviI';A'
T•[: YWtRci RY ONSTRIJ0'11-j v 7TtAtl14( PER. &.ft P,ifs.
r,ALI;ATION 1,0+00,00 i::S
1:w '�..�li'�l �T 11�1.�i�I r. ON,
/0) t..ff Wee, a (
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PF_Cti8iIT F F'C' SrUMMAA
't'i:AIP (:ONSTRA)CT110N T1(jVLE1 101'fN)0-'I2.3 Ui)ft �i��IJ.V11
1 I`K)N AND P1,A.Nw (7)M-�'K
�;'�.�,0t1
��,L13SS P I t E- I}:'SIC) I i.I:s
$0.00
Q• I �,I E �1Oa (6411T F EUS 11.)1111•; NOW
a2�lft,tf41
y .
RECEIPT
DATE
BY
DATE'FINALED
INSPECTOR
i i -
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.
Griffis
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
Sef Backs
Electric Bond
Footings
Main Dwain
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
_G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)