9706-134 (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
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: t
(Y,)' 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 thi reason
mate Signature of Ow
ne
�.
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.
(,,,)r 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:
Carrier 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,
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 shall forthwith comply witK`ithose p:bvisions.
ate: ` Applicant
-11_ -.
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 applicator 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
the/'above-mentioned property,for inspection purposes.
/Signature (Owner/Agent) Y S1 A R �/ ' Date
PERMT#
BUILDING PERMIT
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OWNER
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USE OF PERMIT
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
,10
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
BLOCKWALLA n PROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
_
Equipment Location
Underground Electric
_
Underground Plbg. Test
Final 17U
Gas Piping
PLUMBING AP ROVALS
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
UtiliN�Notice (Perm)
.Print Key Output
5763SS1 V3R1M0 940909 A0365704
I
Page 1
06/20/97 15:55:06
Display'Device . .
. . . DSP10
User . . . . . ...
. . . 5311111
Insured: DAVID LANE &
VERNA LANE HWJT Pol
No: 099170613
10/09
Address: 78600 AVEN LA
FONDA City: LA QUINTA
State:
CA
Home: ( 619 ) 564 - 0320
Zipcode: 92253 - 2842 Org
Year: 87
Agent:
41 72049
Class 6101606
**PROPERTY SUMMARY**
Status ACTIVE
POSTINGS
Clms:
Y Frms: N Dsc: Y
Premium: $870.00+
CASH-DIR MAIL 101196 `8870.00-
Pay
Pln:
MONTHLY
AAP $870.00+
RENEWAL PREM 092596 `8870.00+
Nxt
Due:
`1;0.00+
Balance: $0.00+
811
Act:
FOLUP ISSRN
Lst 811: `1;870.00+
1 On:
10/15/97
Cur Due: $0.00+
ALL
PERILS $500
Due On : 9/21/96
Pol Type: DELUXE HOMEOWNERS
- PRIMARY RESIDENCE
COVERAGES
LIMITS
PREMIUMS
DEDUCTIBLES
BASIC COVERAGE
127,442
$424.00
$500
WORKER COMP -OCCASIONAL
CLASS
REPLACEMENT COST CONTENTS
BLDG STRUCTURES REIMB
EXT LMTS
EARTHQUAKE COVERAGE
-EQ 127,442
$446.00
15.0%
(ENTER) CONTINUE { } (F1) HELP
(F9) VIEW BILL (F10) RESCAN
(F3) QUIT (F4) BACK SCREEN
LAST