9903-016 (RPL)LICENSED CONTRACTOR DECLARATION
l he
aeby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C LU Professionals Code, and my License.is,in full force and effect.
License # Lid. Class Exp. Date
t i LLJ 656.1 ?9. C �3 I.lu3l1+3f
Z ti Date %, k --__K�9S Signature of Contractor' `'• _ -- �'
_J 0 OWNER -BUILDER DECLARATION '
IJJ W I hereby affirm under penalty of perjury thatI am exempt from the Contractor's
~ License Law for the following reason:
Z (' ,) 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 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)..
C)Lin O I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
(L Q WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
LIDH O O I have and will maintain a certificate of consent to self=insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
Q performance of the work for which this permit, is issued.
I have and will maintain workers' compensation insurance, as required by
p U Q Section 3700 of the Labor Code, for the performance of the work for which this
d Lo,`,Z permit is issued. My workers" compensation insurance carrier '& policy no. are:
Carver Policy No.
tOD
`<Q iJ1.A i1:I%1J.fd!) lFf>'
QQ (This section need notbe completed if, the permit valuation is for $100.00 or less)
` J (') 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
3 subject to the workers' compensation provisions of Section 3,700 of the Labor
Code, I hall f rthWith-comply wwith tha provisions.
Dater Applicant '-,--��—;
•Warning: Failure to secure Workers' CompensatioR�)Zjverage 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
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;reguestand for whose benefit work is performed under or pursuant to
any permit issued. as a result of this applicator agrees to, & shall, indemnify
;8 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.
certify that I have readthis application and state.thatthe 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-to[�Innspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT*
DATE VALUATION $2 1,000 f") LOT TRACT
JOB SITE
ADDRESS 36 -SCJ l�EA HER GLEN
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LA QUI -NTA ORC:H„ RID PAIL;TKX'
C, LIST 0.111NSA & SPAS
PO BOX 1716
74-723 JON DRIVE, #A
LA Qt.11N'I'A CA 92253
PA1,i%4 A)E;S&'R't' CA 92260
(7()0. �1Q••ft(1Qt) C13L 4 3,
USE OF PERMIT
PC)0L.'.1- PA.S ALARIvISiRiv12RfUk S SiLkLL B-8 W P,'1 -
1'ltk3-}'I,A.`il't,lc I1.SS.P.t�;C;'i'!()�!• � �.
rt. NJ
MAR 'tit
1999
rtf f� y
ST
M%L)!'�XZ .TIA wi,w).00 L3
`i( OF
LA QU"I STA
."1T
•y
ESTIMATED c74 O rViNSTRIi� a1ION.
r1.A�Ci1DV.�iV
It .lNMI i F ER, SUNNI IllAk"t•
4
P1. AN t Flt~ X !•'Ia:: 1.01-(X )- 4:0-318 140.,V.0
I fl i-()flfl-:11 8-011)(1 $12.; A Rtl
T�WCl- h NK'CAI, i . ii •_ I" '?OL 1ni 11i)n- �: I !)(}l� 02 1.00
��ii,1:,�:: tlt.lC.r1i• t�.ca: •- Paul. Ir,I-uo�-�t7o-Q'i1t7 �•):;:,�o
PI.t.IiMBINQ FEIM -- Pt_K>L loi-(IQQ-111`a-(its) $•27.00,
'L
9)rt-"rr7fIi LC()NT.r.RJ.1C'TK)N AND P1 ,NN t -Hr -.(',K
USS PRE -PAID f I?L?S
$0.00
T4.111r<•At. PERMIT FF*N 00E, NOW
RECEIPT
DATE.
BYDATE
FINALED
INSPECTOR
Z!,
i► FWIN
$;
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 8 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 P[bg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
_ 6
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbin Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Q ,
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) -