0004-138 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions
Chapter 9 (commencing with Section 7000) of Division 3 of the Business ar
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
746159 C42 -_-� �"` € V294
�' �Signature ofCctor mat s? w�
OWNER -BUILDER DECLARATION .
I hereby affirm under penalty of perjury that I`am exempt from the Contractor
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their so
compensation, will do the work, and the structure is not intended or offered f
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with license
contractors to construct the project (Sec. 7044, Business & Professiona
1;0699).
O 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 perjury one of the following declaration
(. ) I have and will'maintain a certificate of consent to self -insure for worker
compensation, as provided for by Section 3700 of the Labor Code, for tf
performance of the work for which this permit is issued.
(�/ I have and will maintain workers' compensation insurance, as required t
Section 3700 of the Labor Code, for the performance of the work for which th
permit is issued. My workers' compensation insurance carrier & policy no. ar
Carver OOLDKH EAOLE INS. Policy No. 1,aIV043066-00
(This section need not be completed if the permit valuation is for $100.00 or les:
( ) I certify that in the performance of the work for which this permit is issue
I shall not employ any person in any manner so as to become subject to tf
workers' compensation laws of California, and agree that if I,should becon
subject to the workers' compensation. of Section 3700 of the Lab,
Code, I shall_forthwith comply with those prov`isions�
,,Da°te: 4-/ ' � � ` 60Applicant � '�
Warning: Failure to secure Workers' Compensation coverage is unlawful ar
shall subject an employer to criminal penalties.and civil fines up to $100,000,
addition to the cost of compensation, damages as provided for in Section 37C
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and restrictions set forth on! h
application.
1. Each person upon whose behalf this application is made & each person
whose request and.for whose benefit work is performed under or pursuant
any permit issuedas a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work, is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating to the buildir
construction, and hereby authorize representatives of this City to enter upc
the above-mentioned propertylfor,inspection-purposes.
Signature (Owner/Agent) Date
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BUILDING PERMIT PERMIT#
Id
DATE VALUATION LOT OW 4-13$ TRACT.
$11625.00
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JOB SITE
ADDRESS
APN
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52-M ,AVIi'.1` W A'VHAA
773-334-013
OWNER CONTRACTOR / DESIGNER / ENGINEER
MM4DOZ,F.1vTRilviRS FR"CISCONVEOA X M4, ECONO WIER SERVICE
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52.990 AVM41DA VILLA 84035 CABAZ()1`i RD,1NDIC, CX92201�,
LAt(YWfA. CA 922,53 PfU.�tt DEWXT A
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92266
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(760)'346a273a CBL#;;312
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USE OF PERMIT
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SEPTIC ABANDON • SEWER CONNECTION LO'W.•MOD PROJECT
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CONTRACT.AMOUNT fd63S.00 LS
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l+:b''q'iA 9fRD COST OF C014h'MCTr_ 1O.Tq
11625bo
I FRAW FEE SUAM411Y
PLUMBING FEE -- SrWER 101-000-419-000 $30,00
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SLIB-TOTAL C0..W8TRUCff.OX AkM PLAW CHF
$10.00
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LF.13.3 :PRE -PAID FEES
$0.00
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TOTALYMUIDTFEESDUE NOW
M100
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RECEIPT
DATE
BY'
DATE FINALED
INSPECTOR
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•
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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
Insulation
Compressor
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 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
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
p O ®O
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) O
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: