9612-086 (PLBG)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
AB 2/28iswl
Date I � _hf) /11, Signature of Contractor)( I
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. 7044,13usiness & 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 declaration6:
( ) 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 have and Will maintain workers' compensation insurance, as required by
8� ; e 16 3700 of the Labor Code, for the performance of the work for which this
6on
permit is issued. My workers' compensation insurance carrier & policy no.are:
Cartier Policy No.
3"I'AT13
(This section need not be completed if the permit valuation is for $100.00 ot� 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' compensatid� provisions of SectGn 3700 oFthe Labor
Code, I shall forth with comply with6hose provisions.e.
Date- 11 1 1 - J-11 Appliri nt ! Ar
. If 1�11 li,
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
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- me ntioned propertsrfor inspection..pu_�poses.
Date Ik 0'.
Signature (Owner/Agenrt,�
DATE
BUILDING PERMIT
VALUATION S1.S0().()0 LOT
PERMIT# CONTROL#
%IZ4186 TRACT 4484
JOB SITE APN
ADDRESS 5X,700 AWNHM 1*11 RRUILk 774424-027
OWNER
JAMIES IV & MONNE BECKER
53700 AWN10A KMIURA
UX QUINTA C A 92253
USE OF PERMIT
IUJNfkINt'1
SUTIC A0,ANtX)N. t)EWfkk CONNECT.
CONTRACTOR / DESIGNER / ENGINEER
D E �� 18 01-,* P, F NO, P1 FX P.1 NCT & Q0 N s, r.
681 115BERROS COL)Wr
(WME13RAL CrrY C& 97214
(61q)327-2200 CAIN. 3577
COMRACT AWDUN"a" 1, 8 0 1), W LS
COST OF CONSTIlUCTION
-000- 419-000
PLUNOT31NO KIP, SHWA 101 v
RECEIPT
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SUIP-TOTAL CONSTRUG 110N AND PTAN�_*IARCX
LESS ME' DFF
-PAI , �.ES $0,00
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T0T AL P If RN -2 I TF E FS OU C NOW
DATE BY DATE FINALEP INSPECTOR
1
1531IM110
INSPECTION RECORD
OPERATION
DATE
INSPECTOR.
OPE i RATION
DATE —TINSPECTOR.__
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
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
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
.Footings
Main Drain I
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
en
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer I atpral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) 17 IV,
ELECTRICAV#PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltne Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
-.1