9907-580 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (corrmencing with Section 7000) of Division 3 of the Business and
Profess.ionals C"ode, and my License is in full force and effect.
License # Lic. Class Exp. Date
6916814 13 07/3112(9
11 '0�4
9171�1 tnr 1e.11
Ddt'e - Signature of Contra
V / , z 2/ __ -
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 B&P.C. for this reason
Date —Signature of Owner
WORKER'S COMPENSATION D ECLARATION
d hereby affirm under penaliy of'perjury one of the following declarat ions:
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 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 & poli cy no. are:
Carrier Policy No.
(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 to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation p . rovisions of Sectiori.3700 of the. Labor
Cod6, I shall forthwith Comply with AJs�e provisions/
,Pat6- 9V99A*4' Applicani
Warning: Failure to secure Workers' Compensation 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.
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 authorize representatives of this City to enter upon
the above-mentioned propertyjfo'r inspection purp - ses
I p
S, nature (Owner/Agent) Date
PEPIMIT#
BUILDING PERMIT 9%)7 -MI)
DATE VALUATION LOT TRACT
q 12-1 hc ( 2 0
JOB SITE! APN
ADDRESS �W55COLDBRGOKUWEI I
OWNER CONTRACTOR / DESIGNER / ENGINEER
TNICO 11.10MES CORP- f.h11T(40 HONIffis C0,111P.
1282W.&WROWHIGHWAX 12182 W. ARROW HWY
UPLAND C'A 9 17&! U1,11AND CA 91783
USE OF PERMIT
PIM0
12(� g.ri, OPENnw, LUS, MR0 ('10 WER
AND PIAN CH4 VECK S45,84
LESS PRE-P.M.0 FEES I SOM
S4.15.84
_0VU, PC, RIMIT VMS DUENOW I
11
RECEIPT I DATE I BY ' I if I DATE FINALIED JINSPECTOR
IN
E.13111NAWE'D MOST 01F rIDINTSTRUCTM
30
DX75.1
PERWI, Fillu SUNIMARV
C0N,8T10JC'TfVN FF2
101 M -4184M
W,Al . 14 0 WFt'K V VV,
94
371
AND PIAN CH4 VECK S45,84
LESS PRE-P.M.0 FEES I SOM
S4.15.84
_0VU, PC, RIMIT VMS DUENOW I
11
RECEIPT I DATE I BY ' I if I DATE FINALIED JINSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
SetBacks
Underground Ducts
Ems & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K 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
Final
Final
BLOCKWALL APPROVALS
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
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notioe (Gas).
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
E)derior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: