9907-558 (SFD)LICENSED CONTRACTOR DECLARATION
khere4� affirm under penalty of perjury that I am licensed under provisions of
'ry
Chaptar 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 Exp. Date
B
�/,Signature of Contra �e_
Date ctor
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 (Se . c. 7044, Business & Professionals
Code):'
( ) I am exempt under Section B&P.C.ior this reason
Date Signature of Owner
WORKEWS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following �declarations:
( ) I have 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 i ssued.
0 1 have and will maintain workers' compensation insurance, as required by'
Skti6n 3700 of the Labor Code, for the performance of the work for which this
permit is issued My worker s' compensation insurance Carrier & policy no. are:
Carrier Policy No.
NTEVUNID
(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 t,o become subject to the
workers' compensation laws of California, and agree that if I should becorne
subject to the workers"compensation provisions of.Section 370Q)of.the L bor
Code, I sball forthwith comply with -.01isions.
Daiie: A/. Al -6 Applicant— -4-e- e4
/1, _( I / V ull
/Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to crimihal 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 perfoiTned 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
1%
construction, and hereby authorize representativ s of this City to enter upon
on purp I �
the above-mentioned propVerty, inspecti es._4—
VSignature (Owner/Agent)
BUILDING PERMIT 'PERMI T#
DATE VALUATION 1,1*104.769.90 �OT B TRACT
JOB S'ITE
ADDRESS 45-195COLOUROOKULNE,
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
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Utl%*"d VIV. AARM RWY
UPLANU CA 90S5
10PLAND CA. 91785
PXIIA)WRI _R049 3319
USE OF PERMIT
SiW-JiLE W.-IffinY DW.P. LIBRG
0D. LOT 13.J,1i,okN X3, -'PW44.T 004S KiOTINCLUIDE WALL
OR IWIL.
POWNRIA110 94.00 8F
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ART IN M800 N.4XCIRS - M 1,92
M.-VELOPER lt,�PACr PERE $1,967.00
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YFAL PEPOWT DUENOW
$1,49169
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RECEIPT
DATE
By i, � - -------
r.FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Farts
OX to Wrap
F.A.U.
Framing
01F —M
Compressor
Insulation
i— K E4
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 APPROVALSV
POOLS -SPAS
Steel
Set Backs
Electric Bond
'Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
—0,15
Gas Test
�7_
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) A c.4
COMMENTS: