9910-081 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chipter 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
39032,3 Col D52 D03 065(00
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: .
( ) 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). .
(.4 I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code)'
() Iam exe pt under Section B&PSC Jor this reason
V ate V Signature of Owners�-_
WORKER'S COMPENSATION' CLARATION
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 issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performancetof the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier F'011ey IVO.
FalitiviEsl S MS..EXCH
.iAXVrZR9VV
(This section need not be completed if the permit valuation is for $100.00 or less).
(�f) 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 provisions of Section 3700 of the Labor
Code, I shal forthwith comply with those provisions. .
"Date: %l Applicant
f l r -
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
thabove-mentioned property for insPection purposes. �F
VSignature (Owner/Agent) '- � ? Date lirL I
BUILDING PERMIT
DATE jo/mi"VALUATION S4,783,00
LOT
PERMIT #
8910-1081
TRACT
JOB SITE
ADDRESS 43-"5 :s;CC.!L WARD "6�b'AY APN 609-470-034
OWNER.CONTRACTOR/DESIGNER/ENGINEER
wLnnrr i N,,k �'.lmpIANg
PO BOX 2267 370 WILLIAMS ROAD
FA0 M D}s':, FAT CA 92260 PALM SPRRK:iS CA 92264
(760)027=22?7 0811 5257
USE OF PERMIT
r°f1IR0
TWO F41.0 Ai.dtl4iiiv` W PAT lO COA ,t (NA S.k' .na 252 S.F.) (1C330
2621P)
JV40 0 F
PERMIT FEE SUM MAKV
CnNStTt21,Y"rr0'KV1^'t; I WI},k'-Q!F!i! 571-1.06
T,0110N AND MAN (14FCK
LESS PRE -I' UD HTS
Tffl'A!1 0rF:ltl iff 1!'Ik':lEN ;<jti)1 N0
s
RECEIPT DATE I BY/ �� I DATE FINALED I INSPECTOR
4,nl M.a t
5119
INSPECTION RECORD
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Hacks
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
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
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
Utility Notice (Perm)