9907-557 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch9pter,9 (�ommencing 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
69WZ4
/AlfI.Date Signature of Contra t
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I 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 -, 6&P.C. for this reason
Date Signature of Owne r
WORKER'S ICOMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of'the following �declarations:
I have and wil I maintain a certificate of consent to self -insure for workers'
coinpensation, 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:
Cartier Policy No.
0.641*� r V.
(This section need not be completed if the permit valuation is for $100.00 or1ess).
( ) 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 ihould become
subject to the workers' compensatio - r vi I ns of Section 3�00 of the Labor
Code, I shall forthwith comply with U e provisions.
11 i nt
D te: Applic
L17 AV
Warnin"g: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civi.1 fines up �6 $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 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 authotize representatives of this City to enter upon
the above-mentioned property fo 'r,'inspection poses
�a Date
Vsignature (Owner/Agentl 7/1A I )PU,
PERMIT#
BUILDING PERMIT
"07,SW
DATE VALUATION LOT TRACT
12
JOB SITE
ADDRESS 45-2i.SCOLDUROOKUNE
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
YIN= 110 MIES CO 'It. P,
INCO I MINIM'S CORP.
1,21S.2 W. AfflkCAV Friv, Y
1292 W. ARROW41WY
UPLAND CA 9 178 5
UPLAND
CA. 9178-4;
USE OF PERMIT
1, 76 S. F. ONN UELL i STik 7110 4' 0 �1-111.
POPV710ATILO MAI 11;F
37004rAT"Z11% 4r.rwlr f*�vpr�OMOI"W"r"U(7117"",.Ii�*�lI
A!, 3 A 4!1" - 9,0�1 A %,IW A, A.41%
So
P E RMIT F E F, S t? M MAR V
C'0NbT10K-*rXQN Ok-E 10t-WO'4184M S3910
tITT W401 -419-311R WN
S,TfWNC,'1N11QT1r0Jq FaIM - RMID 103'. OW -241 M
X1
S1 J19-WrAL (110114 ISIM OCIT(ON ANTYP LA N CH ti CKY
$45-84
LESS P"Itf—ppil) FEES
$0.00
TOTAT,
S45-80
RECEIPT
DATE
BY
DATE FINALED
JINSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
'5et Backs
Underground, Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
A
Ll
Final
Final I't _0v
BLOCKWALL APPROVAL
POOLS -SPAS
Steel
SetBacks,
Electric Bond
FooUngs
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas ii�lping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Nofice (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
Fi nal
Utility Notice (Perm)
COMMENTS: