9604-146 (PLBG).4
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under of
PERMIT# CONTROL
BUILDING PERMIT ' 9604-1146
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provisions
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a°CRapter 9 (commencing with Section 7000) of 3 of the Business and
DATE 4J VALUATION $3,044:00 LOT TRACT
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; Professionals Code, and my License is in full force and effect.
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License # Lic. Class Exp. Date
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ADDRESS 7-842 CAL�.rl�!, I+w�1ti1I�NADA
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OWNER
CONTRACTOR/DESIGNER/ENGINEER
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OWNER-BUILDER DECLARATION
LILIA B J.M.i1;13i,:IA,
HEVDRICKSON C'ON 11RUC IIONI
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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CATHS 1O2,A.Lt'.i7'Y CA. 92234
License Law for the following reason:
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( ) I, as owner of the property, or my employees with wages as their sole
(01.4)_128- 1147 10RLA IN
compensation, will do the work, and the structure is not intended or offered for
USE OF PERMIT
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 & ProfessionalsL��f}3)�ir
Code).
( ) I am exempt under Section , B&P.C. for this reason
SOSVIER C0NNF., 1'15F1Y11C •ABANIX N
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Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION •
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I hereby affirm under penalty of perjury .one of the following declarations:
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() 1 have and will maintain a certificate of consent to self-insure for. workers'
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compensation, as provided for by Section 3700 of the Labor Code, for. the
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performance of the work for which this permit is issued.
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(,); I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
permit is<is9ued +My'workers' compensation insurance cairferf&'p'oli'cy no. are:
081 �AIEi`. ED COST OF CONS
3,044.00
:3,1044.0 0
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Carrier Policy No.
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PLL: ,n11XQFr 31.1W.ER 1.01.—M-419••tDt!(1 $30.439
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(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
3
Code, I shall ortprwith comply with those p o sioras-�'
/a. Applicant ✓ �w
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
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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-
isapplication.
application.
1. Each person upon whose behalf this application is made & each person at
suB- v AI_ C:o1>IS".ri2[,.Ic"1:#m A.I`D PLAN t`' 111ECK
$30.0()
whose request and for whose benefit work is performed under or pursuant to
LESS R-8-PA,(j j LIES.
$0.00
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
T�xTAI- > ',�.$�JIT 1� EES 09!1.3< �® A'
$30100
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
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correct. I agree to comply with all City, and State laws relating to the building
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construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purpose$$g.
Date E' *!
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DATE !
BY DATE FINALED.
INSPECTOR
,Signature (Owner/Agent) ,, �?•
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INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireolace P.L.
Exterior Lath
Drvwail - Int. Lath
Final
BLOCKWALL APPROVALS
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
'Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
POOLS - SPAS
Set Backs 'Electric Bond
Footings . Main Drain
Bond Beam Approval to Cover
Equipment Location -
Underground Electric
Underground Plbg. Test
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 112
Pool Cover
Sewer Connection
Encapsulation
Final
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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)
2502 Morongo Trail
Palm Springs, CA 92264
(619)327-8859
Na 10229
SOLD( TO
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SHIPPED TO
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C I TY STATE I P
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CUSTOMER ORDER JI
SALESMAN
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TERMS
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PAYMENT DUE UPON RECEIPT