9907-050 (PLBG)C14 C0
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LICENSED CONTRACTOR DECLARATION
I 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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Z
,Jairte�_6 Signature of Contractor
& G,
OWNER -BUILDER DECLARATION
I hereb affirm under penalty of perjury that I am exempt from the Contractors
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 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
pe ance of the work for which this permit is issued.
Pave and will maintain workers' compensation insurance, as �equired by
SiRtion 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:
Carrier Policy No.�
&1fD.C%'N"1'UR.Y IINSW A101f) 9 "1 0 9 5
(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 permitis 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 provisions of Section 3700 of the Labor
Code, I shalfforthwith comply with those provisions.
Date, - ADDlicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employerto 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 employee&
2. Any permit issued as a result of this application becom 9s 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 represen Ives of this City to enter upon
�w above-mentioned property for inspection urp s
Signature (Owner/AaenfiW,,.Z-- Date--) /I
77
BUILDING PERMIT PERMIT#
��Po"/_050
DATE 07102/1" VALUATION S.11 59.00 LOT TRACT
JOB SITE
APN
ADDRESS 53-8441; AVE'NRIA C()R*rwz
OWNER
CONTRACTOR / DESIGNER ENGINEER
I-WGINA CY' R RILL.()
VA1,LEY PLUM BIN6
53_89,Z5 ANILMDA COKIT.'ZI
46780 CLINTON
i.,A, (,�.ANTA CA. 921�3
INDIO CA. )212,01
c6t.4 10i
USE OF PERMIT
PLILI&JUNG
WAtER HEEKOVIJ4, WdPLAAC FAfGNT
CONTRACT AZvrt;T4T i's
ESTHRIATE'D IMST OF CONISTRIUC710N
25,M)
Pp"'HMIT P'FIE S(lN44&'iJkRV
PI,0,MB.1NG FEE 101 -ft) -4119-00
`I.MTMALCOMS LA7 10NANDMANCHUCK
iq
LESS ME-Elk1f) HTS
$0.(YJ
TOTAL PERM 11T PCEN DU K NOW
RECEIPT
DATE
FINALED
INSPECTOR
I " I M'', __, I " I#j A! I I IN r 1 1: 1 �:: W. 91 �
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. 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
Ste . el
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 =4r_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Eciuipment 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) W 27"
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G'.F.l.
Smoke Detectors
Temp. Use of Pow
Final
UU14 Notice (Perm)
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