9812-092 (RER)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
CWi LO7.10101 C!.6 7/3V99
oZ r- Date Signature of Contractor
CD O.rl�
J U 0 OWNER -BUILDER DECLARATION
W W r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ ,a 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).
(X) I, as owner of the property, am exclusively contracting with licensed
contractors to. construct the project (Sec. 7044, Business & Professionals
ode)CCode),,.,.-
00
0 OSI am exempt under Section B&P.C. four This reason
N �kte '!a - .4' Signature of Owner t"~�
bpi «,rt
Q WORKER'S COMPENSATION DECLARATION
C) 2 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'
X W �= compensation,- as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
C3 Q U ( ) I' have and will maintain workers' compensation insurance, as required by
Q UQ Section 3700 of the Labor Code, for the performance of the work for which this
d vF- permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
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 manner so as to become subject to the
workers''oompensation laws of California, and agree that if I should become
3 subject°to the workers' compensation;provisions of Section 3700 of the Labor
Code I shall forthwith comply with those provisions.. X
/a ) a,
Plate: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for, a permit subject to the conditions and restrictions set forth on his
4 application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City,, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
V ignature (Owner/Agent) t;; � • X f7! ��� Date 7 �� f�
BUILDING PERMIT PERMIT#
DATE ,vALUATIONLOT TRACT
JOB SITE
ADDRESS 53-U AVE, ,Dl2' , NiDii
APN y -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LED 1. srlarcl r .
rvr."'f. Cojj S • ( u o t c�rnrtsz
9�5 LA .FIESTA WAY
69 a 11`iC+�.1SMR IAL P�,AdJe
sq; N .mxptcos CA 92069
PALM SPRINGS CA. M&
t
(610j,78.6111 t"UP 2410
USE OF PERMIT
G- KI S:n AL. RiJl.JaD1Nl, +
i
REPLACV EUSIT'€+sO DOORS AXTJ VVWDOt;; & .7$ U v FALi.tTs WN—J- 11JM-4Yj
AU -QLJVZi.NG. (`
J
d..
V kLUAT10N ZOO -5.00 LS DEC 3
3 1998
L
t
F.MNINI' ?V COST OF CONIS'd'RUMON
2,08)0.00
P4 RA4,;11' Tib+: +' SUNLbtARV
LE: wiwL"`riorqi4rs 101 -iii -418-000 $45.04
t:l&1=if�};�IL.Cc1R�ST.Rs,iC.;T'iON r�l�tl�Pl.�1t��;a•rF'c";K
$45:00
LESS PRE -PAID }'FES
$0.1)0
TOTAL iy''EROIT FC CS Di)XNOW
4�
RECEIPT
DATE
BY r
DATE FINALED
INSPECTOR
M ;_
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
OX 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
OOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
ond
Footings
in
Bond Beam
Approval to Cover
WLocation
nt Location
und Electricund
Pibg. TestFinal
ngPLUMBING
APPROVALSGasTest
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)