9608-054 (BLCK)U)
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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. Date
(01
. _&A) B
Dat,.A— 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
performance of the work for which this permit is issued.
I I have and will maintain workers' compensation insurance, as required by
S'e'dtion 3700 -of the,� Labor Codej for the performance of theilwork4or which this
t1iX I'll 4�4 111*4 0 1V4lJ,1J0 . . %0 1 - . �1, $414-4
permit is issued. My Workers compensation insurance carrier'& policy no. are:
Carrier Policy No.
(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 Sectio, ?3,700 of h6labo
s
ov
Code hall orthwith comply with -
.Pse prov
Da YS Applican
Warning: Failure to secure Compensation coverage is unlawful and
shall subject an employerto criminal penalties and civil fines up to $100,000, in
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 application is 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. 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 inspe tion Si .
Signature (Owner/Agae-rd, Date
—if
PERMIT# CONTROL#
BUILDING PERMIT 3871,
DATE VALUATION S!%W.00 LOT TRACT
JOB SITE 79-200 FOX'RIN
APN
.ADDRESS
I
OWNER
CONTRACTOR / DESIGNER / ENGINEER
COVE
Xr
Nit I N I.SIRCU, PA 11".) CO VE,
50445 MC)UNWN SHADOWS RD
.5,0445 MOUNTAIN SHM)OWS RUJ
LA QU NTA
LA QUINTA CA 91251
04- 1914)
5'
(619)",64.18,19 C111.0 3625
USE OF PERMIT
4;FNERAI, IWILOINt,'
.20 LIN 1,70F 47 GARI)EN WALL
I -'-S F I iN I AT C, I I CXA. F 0 CG NS TR 11C T 10N
P It' , H N4 IT F K t, 8 t N1 M A It Y
CON-'TrRtr(,-tT0N P1,T* 101-11M.41840) $SfA)(11
Cn
CY)
C")
C D
SUB -TMAL COMMUCMON AN 1) PLAN C1 W C K
$81.00
1, Bil, S 11 R E - PA I D 11 3TS'
$0.00
TOTAL IT4,11041TIVEWS DTIF NOW
S81011
RECEIPT
I
DATE
I.
BY 111�1
I V
DATE FINALED
INSPECTOR
1
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
0. K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
POOLS -SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
PLUMBING APPROVALS -
I Shower Pans
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
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)