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LICENSED CONTRACTOR DECLARATION
I hereby -affirm under,penalty of perjury "'that -1. am licensed under provisions of
Chapter !�(commencing with Section* 7000) of Division 3 of the Business:and
Profe! 'on, Is Code, and my Licens6is in full force and effect.
Lic. Class Exp. Date
7' 1 424 ' (�:_61 . W3097
,4 3
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,prqperty, or my employees with wages as their sole
compensation, will do the work, and the structur& 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, Signatu,re of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one. of the following declarations:
I have and will mainta . in a certificate of . consent,to self-insureJor wo�kers'
compensation, as provid I ed for by Section 3700 of t he Labor C.ode, for the
performance of the work for which. this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Section 370a of, the, labor Code, for the performance of the -work for. which"this
permit is Is6W.' MV"Wrkers' compensation insurance dAAr.T-'Aby no. are:
Carrier Policy No.
(This section need not be completed it 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 man . ner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
su6ject to the workers' compensation, provisions of Section 3700 of the Labor
,0ode, 1 s 11 f h *th comply with th vi I
Date: !2 Applica t v
Warning; Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employeTtoCriminal penalties and civil'fines upto $100;000, in
addition to the cost of compensatior� damages as provided for in S.Ekction 3706
of the Labor Code, Interest and attorney's fees.
IMPORTANT Application is here by made to the Director of Building and Safety
.for a permit subject. to the conditions and restrictions set forth on hi�
application;
1. Eadh person upon Whose behalf this, application is made & each parsonat
whose request and for whose benefit work is pert ormed under or pursuant to
any permit issued as ia result of this applicaton agrees toi & shall, indemnity
& holdbarmless the City. of La Quinta, its officers, agents and employees.
2. Any permit, issued as a result of this appli cation becomes null and void if
work, is not commended within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject!,permit to cancellation
I cepity that I have read this,application and state that the -above informaf ion is
correct� I agree to comply with all City, and State laws relating to the building
nstruction, and hereby authorize representatives of thi� City to enter upon
hie above-mentioned property for,inspection purposes.
Signature (Owner/Agent)",, D a t 614
PERMIT# CONTROL#
BUILDING PERMIT
4095
DATE 9/16/9(i S&929.30 LOT TRACT
JOB SITE 78-795 VWSTAA14LAN D I)H. __T�N
ADDRESS
6"2321-006
OWNER
CONTRACTOR / DESIGNER / ENGINEER
EIAINIE'L It &CHRISTINA DREJSKE
'VONY M. VUARRA * C 0 � I M. C 01.
18 i95 HAKLAN D -OR : - - I- .
3
366 sIVRGEON DIRNE.
LA QUIMI�A CA 97?:S"A
('O.'O'A fvIESA. C"A, �Y2.626
USE OF PERMIT
EX111ALUED iVOST OF CONNSTRMUCTMN.
PERIVIVI, FE1141 NO M MARY
PLA14 C31RCY. FFt� J1014*0-434�119
$90, 00
S"11014111i MOTION F11*1 KESID 10149K)." I1_000 S-69
S
SUB 'RYFA t, 00.N�TLIVXTION A14D PLAN C311"CK,
11VSS VKV41�,UD FEES
'OTA L PERM IT 011 F N0W
$149.19 -
SEP 6.
By -
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR,
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION .
I DATE —TINSPECTOR
B UILDING 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
-A -
Final
Final
-M- 1 (4,116 yy V
'-OPAOVALS
BLOCKWAI I' A
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Locabon
Underground Electric
Underground P1bg. Test
Final,
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing'Top Out
EquipmenfEnclosure
Shower Pans
O.K. forfinish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Applian,ces
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Win Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: