9908-191 (PLBG)LICENSED CONTRACTOR DECLARATION
TCereby affirm under penalty of perjury that I am licensed under provisions of
hapter 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
'146159 C47 b217917ut
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)..
()r) 1, as owner of the property, am exclusively contracting with licensed/�
contractors to construct the project (Sec: 7044, Business & Professionals
2ate'.
g)/
f am exempt under Section B&P.C. for this'Pyeason
� 1,® Ci Signature of Owner 1: i �I--
WORKER'S COMPENSATION DEgLARATION
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 'insuranae*carrier & policy no. a're:
Carrier ��tt yy• p �a p Policy No. /
tJ4.i.1lVihlV ]E.A�tivu L ir5.• .l�fN+l..�NULN¢�"'FJ'.v .
(This section need not be completed if the permit valuation is for $100 0—or-less),
( . I certify that in the performance of the work'for which this�e�'r''mlt is issued;
I shall not employ any person in any f`anner so as to be-coTe subject -to the
workers' compensation laws of Califorriiat\and agree that if fl should become
sugject to the workers' compensation' provisions of Section 3700 of the -Labor
'ode, 1 shall forthwith comply with those provisi • ns.
'Date: e' 14`85 Applicant
Warning: Failure to secure Workers' ,CQmpensation 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,dI' ages 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 Joid•if
work is' not commenced within 180 days. from date of issuance of such
permit, or cessation of work for.A80'days will subject permit to cancellation.
I certify that.1 have read this application and state that the above information is
correct. I/4ree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this Ci enter.upon
the above-mentioned property fo � insp,Sef/c �purposes.'ta' ignature (Owner/Agent) + tte '
BUILDING PERMIT PERM T#
DATE�w�p VALUATION ` soo.o LOT TRACT
JOB SITE ADDRESS 53.452.1 F�Q�x�!aNI91FA VALL.W0
APN 774-122,025 '
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JOSEP" `d BtER
FICOINO Sn"t°VEP SE :'SCF
5332 AVINIDA VALLEJO
84035 civamoN ka r'r1.olo, C 11L 5 220 k
LA q(3�?s 'E� -C A ��a� S'4
Pt 114 DFSPERT Cil. 0X261.
(760)346-2-M CHL4 342
,
USE OF PERMIT
Mr NDOid, Sze . CONI ICT . .
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1,800.00..S
PERMIT FEE SUNWAF41'
PLUMBING FFJ( w•• �t �b`fitt $34.00
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AUG 2 4 7999 '
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SUVt:OTAIT, i.OMI'-RUCU N AND P)A'N CHECK�
�atl.Ctt�
LESS 17 I:=.tMID "EES
.14'
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 Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I 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)
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COACHELLA
VALLEY WATER
DISTRICT
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CASH RECEIPT
DETAIL
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