0012-192 (BLCK)Cl)
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LICENSED CONTRACTOR DECLARATION
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
Professionp� Code, and my License is in full force and effect.
L!;ense # Lic. Class Exp. Date
Date - . Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Licenser Law for the following reason:
(y I, 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I a gxempt/unde ection B&P.C.�for,tN a on
Date7, /` LU ignature of Owner _�''�
WORKER'S 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 LaHor 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 carver & policy no: are:
Carrier Policy No.
(This on 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 -J§ 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' compensati rov Ions of Section 3700 of the Labor
Code�o h d omply wits ll
DPPlicant-
r
Warning: Failure to secure Wor ers' 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 authori.4errep"htatives of this City to enter upon
the above-mentioned prope or ill a purposes.
Signature (Owner/Agent) Date��
J�UILDING PERMIT PERMIT#
DATE/--,! / �` ht VALUATION LOT (�{fj� �!1YIt TRACT
J06 SITE`
APN
ADDRESS
19-•"x'95 c(ACrIEZ Xel NE1,
e -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
4.
RUN AM IN
O4WNE"XIBU.UMM
7fi� 76S 1Ak'd 140--A
LA;?T:11:t4TA CA 92253
(: F C. -MR.
USE OF PERMIT
(311MMIZALRMLDI G
incl [Jf &H URRDEN WAU. MUST COMPLkF'17 I TH Comm L`tzvvLov Mli: IT'
kif?;C!o,1IRRIAW"I'S CY W ROCl(fNT 9i o)dl,;'1 wCilw).A:3 PER NLAA ONLY -
CITY 3'PJ1Ai[915,RD
6 FT, WALL 1611.00 UP
;YMTKATED COST OF ('.C►.['a':r"Mi7i" 0J,
PURAW itiW SITNIM.Il1 '
CONSTRUCTION ITT 101 -000"-.418-000
SUB-TUTAt C;0VK)i:'S.0tJ'f'10H A114i) P;i.AN t;;EMCK
3��2•.tif�
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RECEIPT
DATEBy
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DA F LED
INSPECTOR
k•.C'
IT���P*CQTdll N R E COI ]Pkl*
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
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
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCGWALL-APPROVALS
POOLS o SPAS
Steel
Set Backs
O(
L�o
Electric Bond
Footings
(
Main Drain
Bond Beam
-of
Approval to Cover
Equipment Location
Underground Electric
Final
it ydrof
Underground Pibg. Test
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
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)
COMMENTS:
A RE-IN.SPE ON`FtE OF $30
WILL BE CHARGED IFTHE APPROVED
- — — -PLANS AND 106 CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
NO EXCEPTIONS!
.A lows
A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
NO EXCEPTIONS!
CITY OF LA QUINTA .
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE ! Z BY