9905-291 (RR)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 E Date
CY
36 94
/Da 9e_ W. Signature of Contract
OWNER -BUILDER DECLA16TION
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 , ISignature 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 wdrk for which this permit is issued.
1k). . I have.and will maintain workers' compensation insurance, as requiied by
Secti6n 3,700 of the Labor.Cocle, for the performance of the work for which this
�errnit is issued. My,workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
WC1_01 045
1XION C", I SO 0
�This_section heed not be completed if the permit valuation is for $100.00 or less),
1, certify that iri the performance of the work for which this permit is issued�
1�shalll not employ any person in any manner so as to become subject to the
Workers' compensation laws of Califorla, and ag ' ree that if I should become
subject to t�e wolkers' compensal pn ion ' rection.370Cro_Fih'e Labor
de
Annlinqnt'(;,�
ijfth comply wit/ SX
'is S
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""CDate
arn?ig- 'Failu%reto secure Workers' Cdimpensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
1,
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, indemAity
& hold harmless'the City of La Quinta, its officers, agents and employeeg",
2. Any permit issued as a result of this application becomes null and void if
Work is. no�5commenced within 180 days from date of issuance of. such
permit, or cessation of work for 180 days will subject permit to cancellation.
certify. that I have read this applrcati and state that the above information is)
porrect.,l agree to comply with 0 C
I i and Statilaws relating to the building
'y t Ho resen t,,e -Cif
construction, and hereby autti ize 1presen t' 'es of this y,,to enter upon
i t y
'0
ihe above-mentioned pro or I �fAecXl' os
p es.
t)
/Si nature 'Owner/Anentl A ate
1.6/
PERMIT #
BUILDING PERMIT
990.5-29)
DATE VALUATION S6.9woo LOT TRACT
JOB SITE
APN
ADDRESS 4(k-965 GOLDENSAINMi PLACE
I
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1311).V1% X I IC.1031 Ir"111
R010IFT11LE SPErJALTY
46-965 GOLDIEN SANDS K.
-140 75 Agif PER DR
LAQUINI-A CA 92253
PALM DESEltr CA 92211
USE OF PERMIT
WAIINVW
6,9Q.00 114S
ENT) MATED CO3'P1-'QF CON'=4 k INN
PERAUT FEE SUMMARY
101A00-419-000 $300)
8U8.`!VVAJ, CON$'TRUCTON AND M,iW CW,.CK
LESS fItE.-PAID FEES
�, X11
-0;8
, 6N RN111' FE DVE NOW
CIP-
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
- INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade,
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
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
Sfit 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
Geis Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp Power Pole
Underground Conduit
Rough Wiring
Low.Voltag6 Wiring
Fixtures
Main Service
.Sub Panels
E)derior Receptacles�.
G.F.l:
Smoke Detectors
Temp. Use of Power
Finali*,
COMMENTi'
Lltility,.'Not� ,(P6rmy...,.