9911-019 (MISC)LICENSED -CONTRACTOR DECLARATION
I hereby affirm; under penalty of perjury that I am licensed under provisions of
dhapter ,,9 (commencing with Section 2000) bf Division' 3 of the Business and
Professionals Code, and my License is in full force and effect.
License #" �Liic. Class- Exp. Date
Date �� ' � Signature of Contractor t' ,' per;
p �.• f, t
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from.the Contractor's
License Law.for the following reason: k
( )' 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).
O 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
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 &,policy, no. are:
FCarrier Policy No.
+91 <7. Li !: L/A `iJ - • ° � .. Farii-•?%�,Ctf3Jt+;C �
4(This.section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the wbrk for which this`permit is issued,
I shall not employ any person in any manner so as to. become subject to the
worker compensation laws of California, and agree•thatkif I should become
subject to the workers''•compensati6n provisions of Section.3700 of the Labor
Colde, l shall forthwith comply with those provisions.
vDate:.� 1 ^,— Applicant—l-,,
Warning:, Failure to secure WorkeW—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 thi ;.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
theeabo'v'e-mentioned praperty for inspection purposes.
.Signature (Owner/Agent)` .A -l1 --•-b – _ Date
PERMIT #
BUILDING PERMIT�.4�
DATE I jUO3tJO0#VALUATION ' ; � LOT TRACTJOB
SITE
ADDRESS T.� fl /41"'°*.�0 H �ld�i
#
T
,OWNER
CONTRACTOR/DEESIGNER/ENGINEER
Hsic'gulyJLLen"yt1
1020 C k..s:iT UMBiA ST. iii Xi'
4s X70 CLUB DR VT
6NEATHERFO D TX -76W
IND, WMt,'LILS CA 97.2.IO
(7.6Q)772•14)11 C.81^0 4999
USE OF PERMIT
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3"b€At7:'i,tii�;i''`luit.t�kl.Ct” +-I"fi►
VALUATION 743.xO LS
' tS ai.W.AMA A, M'1-Wa,' OF CO ISA..R4!'C.. 9.ai.6i'3
fW`D'+{f.�TiP
PERMITMIR SUMMARY
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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)