9907-206 (SFD)LICENSED CONTRACTOR DECLARATION
U) 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 Bu�iness and
C14 U)
UJ Professionals Code, and my License is in full force and effect.
=) C) License # Li6. Class Exp. Date
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LU co, -12321 02i25i'_,(�
Z Date 00 Signature of Contra'ctor
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r� I.— C:) OWNER -BUILDER DECLARATION
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LL1 LL1 r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) l,'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).
CO I am exempt under Section B&P.C. for this reason
U')
C\I Date Signature of Owner
0 C\I
< WORKER'S COMPENSATION DECLARATION
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2 Z I hereby affirm under penalty of perjury one, of the following declarations:
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F_; 0 1 have and will maintain a certificate of consent to self- insure for workers'
X UJ Y= compensation, as provided for by Section 3700 of the Labor Code, for the
0 _J _J
J < performance of the work for -which this permit is issued.
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< (,),-I.-h.ave and will maintain workers' compensation insurance, as required by
C5 Section 3700 of the Labor Code, for the performance of the work for which this
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0) permit is issued.. My workers' corpensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
5
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< (This section need not be 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.o.f. Califoinia, and agree that if I should , become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those
Date: �t— V"a Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an'employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damades as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
q 1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to'
any permit issued as a,result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of,work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Sign ature (Owner/Agent) Date
PERMIT #
BUILDING, PERMIT
4NI J'7- 206
.D VALUATION LOT TRACT
JXN 6 6'2000
JOB SITE
ADDRESS 79-61* DESERTUnLOVir liTRENZU
APN
'"9_030_020
OWNER
CONTRACTOR / DESIGNER ENGINEER
C, Irr 1 1 1 IV V VQ I n M.1111f A I
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I J I Ir 1.1� I ILJ k111 . 1.1 f 4.1 , I k�'.i "i it.-$ i 4.S 1 1. J
S.NiRKIIALA, &U17H 400
5 PARK PLAZA, �UtUVE 40Z)
JKVINE i�_A �)213(4
IRVINE CA 92ot4
1949-123 1 .6 100 (JUN 5072
USE OF PERMIT
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10 CAI, PERMff FEES DU k, NOW
13.134.96
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Kj(e4'-
Underground Ducts
Forms & Footings
Ducts
&,P/
Slab Grade
Return Air
Z_ =4,4!
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
;9�t
Insulation
en s
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
-4—
Final Z,
BLOCKWALL APPROVALS
Steel
POOLS-SPAS
Set 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
/13 —2.C> — op/
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
/111,
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) 027-1.4
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)
COMMENTS: