9809-070 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Imo- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full forceJaneffect.
O � ch License # Lic. Class Exp. ate ----
Z ✓ Date Signature of Conr1O
�—
r- U � OWNER -BUILDER DECLARAN _
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ 13. License Law for the following reason:
Z_ ( ) 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 8, Professionals
Code).
co () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
d< WORKER'S COMPENSATION DECLARATION
j Z I hereby affirm under penalty of perjury one of the following declarations:
p () 1 have and will maintain a certificate of consent to self -insure for workers'
K W compensation, as provided for by Section 3700 of the Labor Code, for the
D J Q performance of the work for which this permit is issued.
n Q C) (M) I have and will maintain 'workers' compensation insurance, as required by
j U Q Section 3700 of the Labor Code, for the performance of the work for which this
L 0) Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
Ob o IO rN . Co. yrs .1.®5s( ,15
J (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 ma net so as to b come subject to the
-workers' compensation laws of Californi , and agree th11 if I should become
3;Code,il
subject to the workers' compensation pr isIons�•of-Sec.ion-3700 Labor
S'', 11 �' It "omply wit S' l rouisio s.
Date: ' ��7..�Pplicant :!
Warning: Failure to secure Workers' Co pensation 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
atof 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 gate that the above information is
correct. I agree to comply with 11 City, an - State laws relating to the building
construction, and hereby autho repryAtatives of thiCity to enter upon
the above-mentioned property r i • sp obi purposes..f�7
/Signature (Owner/Agent) Date?"
BUILDING PERMIT
DATE Qrl 9/98 VALUATION S31200.00 LOT
PERMIT # CONTROL #
9180-00
TRACT 8 1 4 6
JOB SITE ADD ESS 52-040AL'.@:tNIDA MAZ APN 77� .sib 002
OWNER CONTRACTOR / DESIGNER / ENGINEER
S'21040. Ail E.NIDA DIAL
74075 5 AS7'CA CA
LA. Cw7UIN'T A CA 97233 !PALM I'ME ?.RT CA 92211
(760)341-61123 CRL0 1420
USE OF PERMIT
C EN. RAi. BUILDING
RLMOWE EMS'T.I NG HOT ROOF "ID i�.iPLACE'ArITH 23 VR Co fin
SK(N'OLIM C LASS "A,"
EROO
3;2{tt�.OG `s.S
KIAjiUT P F: SlJii'd'CetilARY
RE'.R00F FEE
RECEIPT
SUB !�(31`l tSG''Is`�JN tENI� 1'1�AlVC €I ;C: .
LESS P E-PAI.D HES
'1170TAI., PCIMFF FEES JAM, NOW
BY /.Y V-'— ' I DATE FINALED I INSPECTOR
3,2faeo
31
50.00
S3u,ot)
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 -!pt. Lath
Final
Final
BLOCKWALL APPROVA S
POOLS - SPA_S
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
c
Rnal
Wtility Notice (Perm)
COMMENTS: