9902-139 (SFD).� . LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty of perjury that I am licensed underprovisions of
Chapter n (commencing with Section 7000) of Division 3ofthe Business and
pmfe»siono|aCodo.andmyLicense ioinfull force and effect. '
uvenuo# uv.o/000 Exp. Date
-
�Jnlr- 7k
-AX Signature of Contracto
OWNER -BUILDER DECLARATION
hereby affirm under penalty of perjury that. I am exempt from the Contractor's
License Lal� for the.following reason:
(-,) . 1;as owner of the property, or my, employe6s'with wage's as their sole
and the structure is not intended or offered for
'compensation, will do the work,
oo|o/oev. 7044. suoin000u Professionals Code).
(. ) } as �woe, of the property; am exclusively oor�raoting with |ioonood
contractors to construct the project (Seo Business
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 perj6ry. one of the following declarations:
. (. ) l,have and will maintain a certificate of consent to seif-insure for worker s'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Q I have and.will maintain workers' compensation insurance, as required by
§ebtion 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:
CaJrrie�' 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,
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 shall forthwith comply with those provisions
Warning: Failure to secure,Workers' dompen'sation coverage is unlawful arfd
Pall sbbject 6n 'employer to criminal penalties and civil fines upto $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
bf the Labor Code, interest and attorney's fees.
iMPORT*ANT Application is hereby made to the Director of Building and Safety
for. A.. permit subject - to the conditions and restrictions set forth on his
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..
. ermit issued as a result of this application becomes null and void if
wo.rk.is not.com.menced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
| certify that | have read this application and state that the above information is
oo,n6ct.'|agree mcomply With all City, and State laws relating mthe building
oonstmction, and hereby authorize representatives o,this City to enter upon
the above-mentioned property for inspection purposes.
Sidnam� �w» �m �»'oa�
V '` / ,/ / /
PERMIT #
PERMIT,
,BUILDING 9%).2439
DATE 'VALUATION S,214^40 LOT 43 TRACT 28797
JOB SITE
ADDRESS 79-39510RONiA
APN -
OWNER
CONTRACTOR /DESIGNER/ ENGINEER
LA QUNTA CA. 92253
PHOMIX AZ 85034
(02)757-1650 CK-tt 49910
USE OF PERMIT
P,QKC",WPA�ff0 203,00 SF
GARAWCARPOWr 582.0 SF
PERMIT FF.HMUMMARY
C'0NSTTWXCT10N F EE, 101-000-418-000
'10; 41M-419231 9
SlUff-TrITAL rQNVRiA7n0N AND PIAN
LESS M -p", FEE
MOO
TOTAL PERMIT FEES DINNOW
$6A".94
RECEIPT
r1la f1111
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
OX 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 Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater 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) _ Q-
COMMENTS: