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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:
( ) 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).
iG) I am exempt under Section , B&P.C. for this/reason
Date /f y6/-41, Signature of Owner.. r,f
WORKER'S COMPENSATION LrA ATION
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:
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 with those r v�isians.
Date: 42-44* � ., Applicant .��
Warning: Failure to secure 1No`rke s' Copp�rsation coverage is unlawful and
shall subject an employer to criminal perla'tA and civil fines up to $1.00,000, 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 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 p grposes.
I� Signature (Owner/Agent)
Date �k
BUILDING, PERMIT PERMIT,',, 0.4,40 CONTROL#
10/141% 1'611111J'HO 4206
DATE VALUATION LOT TRACT
JOB SITE
APN glt�Y- 11J-t!!ll #
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I;::r AL1) M &IA0Ci71AS7
OWNER .13LnIJM1 ,. 2
79—IIA DIANE DRI Vr.
LA C;,),.fiL+ rA CA CA, 9225.3
360-0.73
rz31.
USE OF PERMIT
i�;ti PRAL tat i11,t
it►(!lf' a`d"!tis`t'r1fPJifffi Wt�I.I, ftt?A1t 1'RttO ir�'�!L PL�>L'N't �1t l�c3i2 k:Kt:;3'i'!NC't t�k?e'ti� Ye1:RL?
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► I'•t'. Ve`ALI, i1►tl.trtt LIF
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R571110li.' FI) COS> f OF COIVST;RaTf.1i 100
J,600.04)
PRItiN'tlIFF 14'F F, NIjM41fiRY
0-aN.1Vf1 ft("TI0N:+ 4, 101-000.41A-000
IRi.1&I'1i:)N AND PLAN C:.141YIN
LtsSS PRE Ff,"FS
$37.00
$0.0
-PAID
OCT 211 199r
1537100
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 6
Ducts
Slab GradeReturnAir
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 AP RO ALS
POOLS - SPAS
steel
Set Backs
Electric Bond '
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Jit
Final
Gas Piping
PLUMBING P 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
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:
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CONFIDENTIALITY NOTE:
The i.nformacion contained in this facsimile message is
legally privileged and confidential information intended
only for' the use -of the individual or entity named below.
It the redder of this massage is not the intended
recipient7, you are hereby notified that any dissemination,
distribution or copy of this FAX is strictly prohibitied.
1i you have received this FAX in error, please immediately
notify u: by telephone and return the original masssage
to us at tna address abgove via the United States Mail.
Thank you.
TELF:COPIER TRANSMITTAL COVER SREET
DATE: fJ/ij(-.f
TO: _6&�,-
TELECOPIOR NO: % % �
DGCUmENT LENGTii: / PA6ES, INCLUDING COVER SHEET
PLEASE CONTACT. J Aldll if 0/c, Z&—.e-
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PLEASE NOTE OUR TELE-C/OPIER NUMBER (909) 885-2132 FOR ,YOUR,
CGt�V1:NiENCE LfGCiC/S �. Alo. orf � .lr %/ �`''� �� /S
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