9604-142 (PLBG)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions.of
4 . Cl apter 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
4 A
Va e Signature of Contractor) /7"" , �%�*-'�=� 7
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, 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).
( ) I, 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.
'( ) 1 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 isti 66610My workers' compensation insurance carTi& &"p'olicy no. are:
Carrier Policy No.
(This section need not be completed if 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 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 shat fo. hwith comply with those p
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 for inspection purposes.
gnature (Owner/Agent) /r► +� r Cate 1^
BUILDING PERMIT
DATE 41VALUATION S1,06.00 LOT .
PERMIT #CONTROL #
9604.442 3216
TRACT
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JOB SITE APN
ADDRESS JUSENHOWEIR DR 773-301408
OWNER AA /`y'� JOSE
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t �7 ! CONTRACTOfR? / DESIGNER / ENGINEER
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!NDIO CA 9220.4 cm.wUl m, arty CA 92234
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CBL# 19.4
USE OF PERMIT
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LESS PRE -PAID FEE'S
TOl.W1 PERMIT F 1+ EN :9DVE NOW ..
$30.00
$0.00
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INSPECTION RECORD
OPERATION I DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sevrer1ateral
Sewer Connection
Gas Piping:
Gas Test
Appliances +
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)
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electri
Underground Plbg. '
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Fina
Equipment En
O.K. for Finist
Pool Cover
-� COMMEI
SANCO -
PUMPING SERVICE I
2502 Morongo Trail
Palm Springs, CA 92264
(619)327-8859
N! 10237
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PAYMENT DUE UPON RECEIPT