9711-055 (BLCK)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
t31 7
ell
�te� L14 . 0Signature of Contractor
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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).
( ) I, 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:
( ) .1 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:
Carriere '`i, '� 3'Y l,"�i Policy No. 1`19-97 UINI t' 001.29
(This section need not be completed if the permit valuation is for $100.00 or less).
() 1 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
Object to the workers' compensation provisions of Section 3700.of the Labor
,Code, I shall fort with comply with tho efprovisi
,Code,
J l Applicant // —}y .
t ter'
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 0 a Labor Code, interest and attorney's fees*.
IMPORTANT Application is hereby made to the Director of Building and Safety
for. a permit subject Ito the conditions and restrictions set forthon his
application.;
1. Each person upon whose behalf this application is made & eac_h.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 cessationfof�work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above informal do 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
th4 above-mentioned property for ' spection purposes.
/Signature (Owner/Agent) .f Date 4b -2).
BUILDINGPERMIT PERMITk CONTROL#
DATE .1 Q'Y��}i VALUATION .,�s;,i LOT TRACT" 8322,
JOB SITE ADDRESS 5. -0495 AVENIDA V E�.l�i..EJO APN
t
OWNER CONTRACTOR / DESIGNER / ENGINEER
LINDA T�,�„tYTG9.1l�t f.",i t IA 1 :111'i e14� i" o.fi.i,Y i.sG 11S. f41 ta+4.4��'i'1 Ci1,1
5109S AVENIDA VM,LE10 72372
-LA QfJjNTA. CA 92253 TtriT`3t.'.i110 MIRAGE, CA 92110
72
USE OF PERMIT
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6 FT. WawT t &OO LV
I"ONSTRJJIC110N FSP 10)-(}t4f1-414-000 X72 00
('' INSIR.0 "F10 ANC) pl-.AN r1TK''K
LESS
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[RECEIPT — DATE t= BYE/ 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
BLOCKWALL APPR VALS
POOLS - SPAS
steel
Set Backs
Electric Bond
_
Footings
Main Drain
_
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
.
Underground PI . 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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole j
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: