9908-099 (PAT)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 ytr
260�JS4 B,
,,,Date �; " ��' JSignature of Gontractor�t� A { .J LA
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 perjuryone 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 camer & policy no. are:
Carrier Policy No.
(This'section need riot be completed 'rf 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,37gt) of the Labor
Code, I shall forthwith comply with -those provisions. , *
i:1 i t
r
p te: �='- i:.. '�'APPlicant �• �
Warning: Failure to secure Workers' CompensatioI4 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 Se6tion.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 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. 1 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 bove-mentioned property for inspection pui0oses.
ly { N
gnature gent) '-E te(Owner/A• Fr' 'L
- BUILDING"PERMIT PERMITA ,
DATE (1W1f,,11,99vALUATION -0,745 LOT TRACT. <
-JB SITE
ADDRESS
APN -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�.ii+�l.. ���j•A
��i�..l..i:� ei'.4'� ..,� )i+t''.�ri.�i}�.��`:�i
45.280 DEBBIE T)R.tV'
7-U)91 S WEPC Wt LL ROAD
LA Q)U NTA CA 92253
1'3-:0U%S,+j'!\ D PAUMS CA 1722,*76
ifA$861-2769 C' -BI_;' 3106
USE OF PERMIT
�1'_ti :�.��'. P1.t,t1i4'ti(?�iUil-'t �•li�tT!'iit:e; �"'t!1 (�i:l t;i.�i l�'C3i7� �Ot�f�Chi 'ii :?i1:�) '..
Pt3 tL"I'flx�=+"t"i%i 432.00 S
arl + �v,� v`"r t �• i�< <v+�rs raarra�x �5
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,r re tf`ti
5' '74 15.
ii'FkU 4 F"Ll , SIt, NWAKV
PLAN CUD- F•F1' idt.l40)-4319.318 $52,65
��lllilf'1'r� lt[� itl•%iM fel:_✓:, t{.i: �•.s�,V Lt�A-"1/i('i(�-.1•iA `l1V aI �. j�
5
,.'tY`.WAI.("ONNS>'Cj?fr(".f�tlF ANDf''t..,P, f t;:f1.
I'VIRMil' FMCS DUE NOW
jT(Yd'.kik,
RECEIPT
DATE
BY ; DATE FINALED
INSPECTOR
OPERATION.
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUI LUNG APPROVALS
MECHA=AL 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
B LOCGSWALLL 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
PLUMAPPROVALS
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
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:
PELLETIER
CONSTRUCTION
Remodeling • Painting • New Construction
. 67,4 T-
Pile Mcros
�-. _. 74691 Swiaet'WiQ'�
���?TioMMUM64 CAM76
In l�ey9�{rnch
z-
,/ 30
A RE-INSPECTIO
J FEF ,
WILL BE CHARGED
F THE APPRDI,-
PLANS AND 10B CARD
ARE NOT ON
THE SITE FOR
A SCHEDULED
WECTION.
.NO EXCE
TIONS!
CITY OF
QUINTA
BUILDING & SAFETY
DEPT.
APPR
VED
FOR CONS
RUCTION
DATE
I BY �l .
J
L, Z)
LL,
`ll
74-691 Sweet Well Road 9 Thousand Palms, CA 92276 9 (619) 343-3364