9604-119 (RR)LICENSED CONTRACTOR DECLARATION s
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
Date 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 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) .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 declarations:
( ) 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier &. policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(Q -1 -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' compensation provisions of Section 3700 of the. Labor
Code, I shall forthwith comply with those provisions.
+' Date: 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, 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-mentioned property fo6rispection purposes'
i�gn\ature (Owner/Agent)Date i"
BUILDING PERMIT PERMIl6�I.19 CONTROLN
3200
DATE 4/23/961 VALUATION S2.U00,()0 LOT ' TRACT
JOB SITE
ADDRESS 52-030 EISFANHOWi. R DRIVE
APN 773-231-027
OWNER
CONTRACTOR/DESIGNER/ENGINEER
'110 3ERT W. LINCOLN
-
52030 EISENHHAVER UR
1A QL1R, I'A CA 92253
USE OF PERMIT
GENHkAL BUILDING
RE11.UQF OWNER TO USE C.V. ft.00F TNN TO HOT .MOP
WFIrNU'I`ED COST OF ('F)N:i'T°.RUM ION
2,(4)0.110
.
'!'t:Fst�t'►(� Z'EE ' J0�-tltli)�13.i<1d)f) $30.6!{6
I
S013w70TAII CQN!. 'r1itK:'1 k.0V.:AND PLAN CHECK
$30.00
LESS Pfi.1::-PAID F'Fs':U
$0A)
01.0 ,off+
. �I� a►►ar ES , K01V
3�3.(p0
A P R 2_5 1996
BY
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD •
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 PL. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final may' 6 POOLS - SPAS
BLOCKWALL APPROV LS Steel
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
d
II
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 Connection Encapsulation
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)
I
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