9907-547 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
lchappL'�b (commencing with Section 7000) of Division 3 of the Business and
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04 LLJ Profession6ls bode, and my License is in full force and effect.
(7; 5 License # Lic. Class Exp. Date
P_ CY u.)
LU 691684 07/3 1 PM
e of Con
Z r- Date"'- Signatur' tractor
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r.- I.- C) OWNER -BUILDER DECLARATION'
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LU W I hereby affirm under penalty of pe r jury that I am exempt from the Contractor's
U) License Law for the following reason:
Z 1, as owner of the property, or my employees with wages as t i hei , r 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 & Profe�sionals
Code).
ce) I arn exempt under Section B&P.C. for this reason
LO
C\J Date Signature of Owner
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0)
< WORKER'S COMPENSATION DECLARATION
CL
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C) a: I hereby affirm under penalty of'perjury one of the following declarations:
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0 1 have and will maintain a certificate of consent to self -insure for workers'
X W L -L compensation, as provided for by Section 3700 of the Labor Code, f6r'the
0 _J _J performance of the work for which this p er mit is issued.
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< L) I have and will maintain workers' compensation insurance, as required by
Sect
ion 3700 of the Labor Code, for.the performance of the work,for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are'.
Z Carrier Policy No.
IL 14MY" 14T,
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< (This section need not be completed if the. permit valuation is for $1 o6.00 or.les.$).
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 t * o the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensatioy provisions of Section 3700 of the Labor
IVACode,,,116hall forthwith comply with t I rovisio , ns
.Jiose p
D e A
at Applicant- Z-4 A -U=
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��Warning: Failure to secure Workers' C . ompensation coverage is Unlawful and
shall subject an employer to 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. I . . . I
1. Each person upon whose behalf this. application is made 9 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 1.80 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-mentioned property for inspection pur oses.,�
S*6/ature (Owner/Agent) _74""A_ �16ate -72—
PERMIT#
BUILDING PERMIT
.9997-$47
DATE / VALUATION 0 LOT TRACT K;995-51
,#9
J1013 SIfE
ADDRESS 1454" COLDBROOK LXNE
604AI40-021
OWNER
CONTRACTOR DESIGNER I ENGINEER
Wrl'o HOMPS CIORP,
MCO HO!NIES C_`0`1".
1282 W. ARROW HWT
I'M W. ARROW HWY
AJIPLAND CA 91795
UPLAND CA 91785
USE OF PERMIT
SINGI[X'.. RAWL V UWE LLN6
STFD- LOT 6, PLAN ZBK- 7PORMT DiDf�& NOT W-01turX BLOCK WAIX
Tri. AM" CC, NMI t =1 10
PORCO&ATIC) 1.51A) SF
S91
A Mv PVC "1
50
J 1 f,JRMJT FRcE SUAIMARY
NM-- (7). 1AINICAL 1',01Z
NIUM.61WIt FEE
S71TA-IMIA, I - OOKSTjR VCTONANO PLAN Off,.T%
12 (111
LESS YTZE-PA1DR',TS
$0,00
91�
RECEIPT
DATE
B Y
DATE FINALED
TINSPECTOR
N11-4
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Sit Backs
Underground Ducts
F6rms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
i-?--
Exhaust Fans
OX to Wrap
-Lei
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
Final
Final
POOLS -SPAS
BLOCKWALL
APPROI%LS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
AZL_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
'ZI—C4
Encapsulation
Gas Piping
Gas Test
Appliances
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
Mlity Notice (Perm)