9905-282 (TT)LICENSED CONTRACTOR DECLARATION
U) 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
C'4 'Professionals Code, and my License is in full force and effect.
=) co License # Lic. Class Exp. Date
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I Z P.- L_ Da"'t e Signature of Contractor,
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F-- C) OWNER -BUILDER DECLARATION
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LLJ , Uj r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
co License Law for the following reason:
Z ( ) 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).
cr) I am exempt under Section B&P.C. for this reason
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C%J Date Signature of Owner
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— < WORKER'S COMPENSATION DECLARATION
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rv- I hereby affirm under penalty of perjury one of the following declarations:
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, F;..; 0 1 have and will maintain a certificate of consent to self -insure for workers'
K UJ �= compensation, as provided for by Section 3700 of the Labor Code, for, the
D _J _J perf6rmance of the work for which this permit is issued.
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<� I have and will maintain workers' compensation insurance, as required by
J 0 Section 3700 of the Labor Code, for the performance of the work for which this
2� Lo� pe�rmit is issued. Myworkers' compensation insurance carrier & policy no. are:
It Z Cartier Policy No.
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(This secZA01-A It"Pe completed if the permit valuation s' %VHO or les '
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, 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/Provision
Date: Applicantq
Warning: Failure to secure Wo i�kers't(�-Ibm pen sation coverage is unlawful and
�hall Subject an employerto crirfiinal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
bftlie Labor Code, interest and attorney's fees.
IMP ORTANT ' 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.
4 1 1. Each person upon whose behalf this ap plication 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.
I 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
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permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and itate that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and h6reby authorize repres.entatives of this City to enter upon
the above-mentioned property for' inspecti,oh purposes.
i4ture (O'wner/Agenfi Date
PERMIT#
BUILDING PERMIT
DATE VALUATION LOT 9905-282 TRACT
_ " I I N
,3 - jL
JOB SITE
APN
ADDRESS
I
57-64S CLAREY COW
OWNER CONTRACTOR / DESIGNER / ENGINEER
P,0BERT & CARLA D1X'0N ANDREW PIERCE coRi,,oRxrI0N
6457 1A1%1ES ROAD 44-835 DFF.P CANYON R0 I ,
RETHENDORF 1A 541722 PAL&I DESFRT CA. 92261
(76q)'_%46-3228 CBL# 3031
USE OF PERMIT
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TEMPORARY TRAXER - PGR KJP 98-099
'VALUKrION
ESTUNIATED COST OF CONSTRUCrION
PERMIT FEE 901MARY
TFAIP CONSTRtICT10IN TRAILE1 101�000-423-000
SU840TAL CONST.UXTION AND PLAN CHECK
$200.00
uss PPe-PAfr)r.rc-s
$0.00
TOTAL PERMIT FEES DP�:NOAV.
S200.00
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I
RECEIPT
DATE
BY "� '
I DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I IN PECTOR
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.
Grills
Fireplace T.O.
Fans & Controls
Patty Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I I
Underground P[bg. Test
Final I 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
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Final
COMMENTS:
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)