9907-113 (PLBG)�. LICENSED CONTRACTOR DECLARATION
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
.-Profess Code,,and_ my License is,in full force and effect
License Lic. Class' ; Exp: Date
#
X42715:5' `�� 2 OQ8W201 >'
vate "/ Signature of Contractor k"
' -
OWN ER-BUILDEWDECLARATION '� a
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: a
( ) 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 offe'redfor , ,
sale (Sec. 7044, Business& Professionals Code).;"
( ) I, as owner of the property; am exclusively 66hti'adting WIt11 Ilcen5ed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
(') I am exempt.under Section B&P.C:'for this reason
Date Signature of Owner F ''-
WORKER'S COMPENSATION DECLARATION' -"
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.
(X) 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.
FULPArA14--MtiD :tas UT3079r47
(This"section need' not be completed if the permit valuation is for $100.00 or -lest).
() I certify,tliet 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 ®rr visions. 1
i.Date: �— G Applicant �3f `_'� 0 f
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an el'nployer to criminal penalties and civil fines up to $100,000, •ih .
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 appllcation:ls 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. 1,9gree 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. -
/Signature (Owner/Agent) Date : f 97
r PERMIT #
j f2 T BUILDING. PERMIT, 041
DATE,1. , l d VALUATION5 { i y� LOT + TRACT r
JOBSITEf ala':
ADDRESS /= Si -7! ®6b�' +N� )A Vg.B LA
APN
773.133-023
f
OWNER `
CONTRACTOR / DESIGNER / ENGINEER;
DAVID A'pb, W)"
RO cyrEk
"i' � X40 t1 J 'AII%iA ,V- -' s.
LA QUINtt� i {4'yy ��� ,9�'25� �
#iy�yMl�iq' CA
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�J'254-3f�60,�y
LI# 10...
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USE OFyPERMIT
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101-M 41.9-00 $30..00
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LESSTRE-PAI.D.FBES'
$0,00'
NOW
$30.00
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'
RECEIPT
DATE
BY '
DATE FINALED
x�
INSPECTOR
G
. ,S.
r -1
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 - 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 ,. _
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:
11 1
'COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL .
iNii 74330
ate.
3
Water Service
STEVE . INSPECTION LOG DATE i 67, 3
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