0009-124 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H . Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
(V l Professionals Code, and my License is in full force and effect.
O > M License # Lic. Class Exp. Date
67;120- . B
oZ r_ '-bate I ' ` �' Signature of Contractor ' •r/Ji �~ °�
I'- F- C> OWNER -BUILDER DECLARATION
J UJ d
I hereby affirm under penalty of perjury that4 am exempt from the Contractor's
U) 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 & Professionals
Code).
ch ( ) I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
a)
CL Q WORKER'S COMPENSATION DECLARATION
< Q I hereby affirm under penalty of perjury one of the following declarations:
FQ- O () 1 have and will maintain a certificate of consent to self -insure for workers'
K LI LL compensation, as provided for by Section 3700 of the Labor Code, for the
nJ Q performance of the work for which this permit is issued.
Q U () 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
i U -))F- permit .is issued. My workers' compensation insurance carrier & policy no. are:
IT Z ao -)i�'FB1 M0147 COMPEN3 Policy No. BBSO.0600-19320
r. 0
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' 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 provisions.
Date- Applicant
4 .Applicant "
Warning: Failure to secure Workers',Compensotion coverage is unlawful and
shall subject an employer to crirnih9l penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
r 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 ate
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 employee.'"
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.
vSignature (Owner/Agent) Date
BUILDING PERMIT PERMIT*
DATE VALUATION LOT OWD-124 TRACT
JOB SITE
APN
ADDRESS 52-124 ]3Ui'VVLFVDF L:o1P))i:T
-
OWNER
CONTRACTOR/ DESIGNER / ENGINEER
MR 1V= DOLiNAR
A EXR:I W i'mtm CC.1RpoR.ATICIJN
52-124 DUNUVIE COURT
44835 DIX-P CANYON RD
LA QUINTA CA 92253
PALAd DEScUf CA 97.261
Q60)34.6-3228 C.°BIA 03031
USE OF PERMIT
G17N.1J12.AL. BURDING
100'1,1? X & OR UNDIPA BLOCKWALL (PROTO WALL)
4 Ff. WALL l0S�,90 1,i7
�
Eb"S TFD C09T OF CCINGMU ."I:1OR
PERM, FEE t1Cr "y
CONSMOT1ON PEE 101.000-1.18-000 $13.09
s
.4r i
«
SUB-gOTPS.. C&grRU'C'.'l.[ON ANT) PLANCHECK
$33.00
1 M 0 PFS -PAD F :.S
$0.00
`UO'.0:'AI, PL�I�f�9:fT l YES DUE NO W
=,im
RECEIPT
DATE
IBY
y'{ {�;,.�r
DATE.FINALED
INSPECTOR
!
VV
INSPtCTIt�N REQ%�L
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
SULUNG 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
®LOCKWALL 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
PLQD6NaWNG 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)
ELECTRUCAL 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: