9909-152 (RER)M
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty qf perjury that I am* licensed under provisions of
Chapter' 9 (commencing 'with Section . 7000) of Division . 36 1 f the Business and
Professionals Code, and my License is in full force, and effect.
Lic0se # Lic. Class Exp. Date
e' ignatLi I fe of Contractbr-!�7e--�P. 61a-A,-"-,?,1W1-
Dat
S
OWNER -BUILDER DECLARAT16N`%
41 hereby affirm Under penalty of perjury that'l 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
gate Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perj . ury one.of-the following. declarations -
I have and will maintain ' a certificate of consent to self-inpure-for workers'
compens tion,, as provided for 6y Section 370b. of the Labor Code,'for.the
pe, Once of the wo, * rk for which t1iis:permit ig issued.
ave and will - maintain workers' compensition 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.
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mr,,Ynru" v4sur, -E
(This section need not be completed if the permit valuation is for $100.00 or le ss).
I certify that in the performance of the work for which this permit is issued,
1. 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 3760 of the Labor
Code, I shall forthwith comply with those provisions.
Datef— Applicant
Warning:. Failure * 'to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines'Up to $1 00,000,Jn
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 i s 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- m entioned p'ropert�y,fdr h4spection purposes
r/Anentl
Sinnature (Owne' 6,4� ��Ate
PERMIT #
BUILDING PERMIT 'IA
DATE VALUATION LOT_ TRACT
SIXW75.40 4'2 470
JOB SITE ---
ADDRESS CITiV110N COURT
TAP
OWNER
CONTRACTOR DESIGNER ENGINEER
41A
1AWAYIN, E- C&I RQ'40
78.n.o c-oiux, isuw u2%
"EDINA
1,,.A Qui, lvrq CIA 9-2 2 -Ilc-
(7650)7774611
USE OF PERMIT
Al REW-M)"CIL
74-091 h - ST
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TO PIRWIT �WV7-020 COWEXt-ING WiLF C'ART GARUGG
TO GA1MkXC9JM' W."N311(OCT1014
CUSTOU DONUS ROONI (0,014VE'l Z38 -W 3F
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PEIRMill FEE SIUMNIARN"
PLAN CHECK FW- 101 -OW -439-319 5
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L.ESS PRE.-PA"(D FICIES
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7- it t
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE I
INSPECTOR
BUILDING
APPROVALS
SetBacks
Water Piping
Forms & Footings
Plumbing Top Out
Slab Grade
ShowerPans;
Steel
Sewer Lateral
Roof Deck
Sewer Connection
OX to Wrap
Gas Piping
Framing
Gas Test
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
Final
BLOCKWAL�'APOROVALS
Set Backs
Footings
Bond Beam
OPERATION I DATE F INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
ExhaustFans
F.A.U.
-.POOLS - SPAS
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans;
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
COMMENTS:
Utility Notice (Gas) I I
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)