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LICENSED CONTRACTOR DECLARATION——
J 'm _U 'e' penalty- of perjury. that I am licensed under provisions of
4_ _'§q�comr%ncing wit . h Section' 10001 of Division �.'of, thebusinessi, and
r
Professionals Code, and my License is in full force and effect.-'.
Lilcense # U Class, Exp.,Daik
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C J.,J
69,5354
.\Ate-� S_ ign-ature 'of Contra6tQ/VZte_ AYZI,4�
-OWNER-BUILDER DECLARATION j'L'%�'
I hereby affirm under periaity of perjury that I am exempt from the. Co t 6 es
License Law for the following reason:
1, as, owner of the property, or my. employees witht wages� as eitsol,
compensation, will do the work, andthe structure is not intend or f 0
sale (Sec. 7044, Business & Profess!6�als Code).
1, as'owner of, the property, a ih,6)(clusively contracting -with lk hsed
contractors to constrfuct the project, (Sec. 7044, Business A, Prof ssionals
Code).
I am exempt under Section B&RC. for this'reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm �Unicler penalty of perjury one.of the following declarations:
I havaan .1 cl, will maintain a certificate.of consent to.selfLinsure for %�orkers'
compensation,, a's provided for by Section. 3700 of the Labor Code,� for,the
perf9rmance of the work for which this permit,is issued.
JA I have. and will maintain workers'-,comp�ansation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit'is issued. My workers.' compensation insurance c I amer & policy no. are:
Carrier Policy No.
A OD 0 a e.
(This Section ribed not beCompleted if the permit valuation is for $100.00 or less).
I certify that in the performance,of the work for which thisipermit. is issuedi-
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' compensati" prov.isiongpf S tion 3700.ofthe Labor
Code, I all fortm, th complywit se provis' . i
Applican
Warning: Failure to secure Workers' Compensation covet ' agd..is�'unlawl`J66d.
Shall subject an employer to criminal penalties and civil,fines.up to:t106,066, in,
addition to the, cost of.compbhsation;�damages as, provided or.,in,. i,,F�tioh 3706..
of thdtiboir Code, inie��st,'�r�d'��ftorhpy,�'s�*f6i§s.'
tor
-A` . .... i. ' i &
impokTAiI ppilicatidwis here y'm4de the -Director 6fB6ilding'and Safety
a,.Ipermi - subject to the conditions and testrictions set forth on his
ap plicati.on.
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.
1Y
I certify that I have read this application and state that the above informatioh 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, r inspection
/ �Pu ges.
Y7
Pgriature (Owner/Agent ate
PERMIT #
BUILDING PERMIT
DAT TRACT
)VALUATION LOT
JOB SITE
ADDRESS -51-020LISENHOWERDRIVE
r
:OWNER
CONTRACTOR DESIGNER / ENGINEER
my" IWW" cl, o.iI
JX t_�
SA." S PENCE CONCIPAIW(
1_215 HICH _�y 86
C.! A
1141�Wkto% C A !-.4'22 7 4
A
("BLU 3061
USE OF PERMIT
CILMRP(AL a LEA J
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C-1, It .0 VI X1, 'iO "�p A 1� "AI A 1k k, -.4 #L 11 'A
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FfiF k01-(h*-418-tA1 S27.00
f 4
PIKEA'PUD FEES
P �'.*M IT F KEN 1) U �,MVV
RECEIPT
DATE
BY
/�:R_VD?
INSPECTOR
OPERATION
I , DATE
I INSPECTOR
OPERATION
I 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
I
Final I i
Final
SLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final 9V
Gas Piping
PLUMMHd 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 Connecton
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
Utilitly Notice (Perm)
COMMENTS: