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LICENSED CONTRACTOR DECLARATION
I 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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. D t
651042 C36
Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
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
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
Werf mance of the work for which this permit is issued.
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 carner.& policy no. are:
Caiiier Policy No.
not be.completed if the permit valuation is for $100.00 or.less).
(TZ, secA6 "ne A
.1 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 Californiwnpcl agree that P4 should become
subqpct to tqe w?;,kers' compeinsation'provifions c, idn 31700 of the Labor
Colde; I #s 11 fo hwith comply with thosefrovisionlos
VDate: Applicant—
Warnin n coveZlge is unlawful and
I g: Failure to secure Workers' Compensatio -
shall subject an employer to criminal penalties and civil f6ines up to $100,000; in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, inte.rest 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 at
whose request and for whose benefit work is performed under or purs i Liant to
any permit issued as a result of this applicaton agrees to, & shall, indempify
& hold harmless the City of La Q6inta, 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�ancl state that the above information is
- I
correct'.' I agree to comply with alTICity, and State lavnsrelating to the building
construction, and hereby authorize representatives o t is City to enter upon,
tio
thdabove-mentioned propert for ins ec P? ��Io e/s.
" "'Y' Is
7� / -
Xignature (Owner/Agent) Date
BUILDING PERMIT PERMIT# -
, 4,,- - 1. .. .
DATE VALUATION LOT 9"7-4.11 TRACT
v/1099 S300.00
JOB SITE v
APN
ADDRESS
I
7X"5 CALLE FKL.TP]b..
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LINDA HENFBR'Y
CORTE-7, & ASSOMIES
78-4455 CALM- FELIPF
78,17 SVL BOX
LA QUINTA CA 92253
VICTORVILLE
CA.
92392
USE OF PERMIT
P i 91fN4103
MPLACE] WATER HEA 7101
V"AWAX10N 3W1.00 LS
&STIMATED CMYOF COINSTRIIXTION
PERIMIT FEE SUMMARY
101-OW419-000
V7
SUB-T(N.A.L CONSTRUCTION MC PIAN CHECK
$22.510
LESS PRE -PAM FEES
$0.00
MAL PERIIi-11T FEI US. DUE -NOW
$22.50
RECEIPT
DATE
BY
UA I r r1NALrLJ
JINSPECTOR
INSPECTION RECORD
OPERATION
I DATE I
INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
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
POOLS -SPAS
BLOCKWALL APPROVALS
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
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)