9608-082 (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 1000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
Licens ec.,flas Exp. Date,,,,,-,
A608 _?4 C42
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, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professional.§
Code).
a exempt under Section B&P.�. for this,reason
"'Date r9 ignature 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 forby 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 �vhich this
permit is issued. My workers' compensation insurance carrier &'policy no. are:
Carrier Policy No.
CNA.
'(This Section need not be completed if the permit valuation is for $100.60 or less):
I certify that in the performance of the work for which this permit is issued,
I shall riot 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, Ashallforthwith comply wi those ovisi6ns.
t'tbiate: -1 2' L Applicant W ., Lpr
Warning: Failure to secure Work��r,s'*Compensatio"n"c*overage.i s unlawful and
shall subject an employerto criminal penalties and civil fines up to $100,006, in
addition to the cost of compensation, damages as provided tor 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 *reStrictiong' set forth on- his
application.
1. Each person upon whose behalf this application is madeA each'p6mon �t
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 Jndemnify
& hold harmless the City of La Quinta, its officers, agents and em�loyees.
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 cancellatio n.
I certify that I haveread 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.
/Signature (Owner/Agent) Date
PERMIT CONTROL#
BUILDING PERMIT 3907
DATE $127196 VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
4�4
OWNER
CONTRACTOR DESIGNER ENGINEER
JOHN I DERDSA
01kTRILAN D CONS-117RUMIONT
5221 7 EISENHOWER L -R
5030% HWY 111
'
LA QjRNTA. C.A 92251
COACHELLA CA 922-36
019).39.9-5544 CBL# 31
USE OF PERMIT
SEWT-Ift CONNECT/sISPTIC ABANrYON, WORK CONVLET W�'MHOUI.' rT AMS
Vml�fl: W() 17.T
A.00, OWNER OAS 301,0 VROPER'11� ANP FIA -3 PULYN) PERMIT FOR SALE. TWOK)T HOLUB
FOR. F A -L), AM SIZE OPWASTH.PIPH ARPTO HE PROVIDEDAN.13 VD11FICATION Or, SEPT!C
4-�Wfw, ho V
VALUATION I's
FLUNIBI NIG IFEE, �-.SEWM 10t.-000-419;000
CD
a)
SL113-1,1QrAL, CQN9fRW110N AT,1D PIA� CHECK
$30.00
E 1AF_-`PA,1 -.S
L NS f FIEF
$0.00
'M_Ukt, VERAI 11'FFEN DUE'NOW
$30.0
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
I
OPERATION I
DATE -1
INSPECTOR
OPERATION I
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
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
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
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
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 le
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 Nolt�e (Perm)