9612-079 (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 7'000) of Division 3 of the Business and
Professionals Code, and my License is in full forrce and effect.
License # Lic. Class Exp. -Date
A 1.4
Deite Signature of Contractorf—t
OWNER -BUILDER DECLARAT-ION
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 Cocle�.
( ) 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 pena ' Ity 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.
AA-11have 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.
5 0
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(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 o I f Se�,61ion 3700 of theiab6r
Code, 11, shall forthjwith comply witKthoseA,,r9vi ions/
Date: �4 t Applic t I YN
Warning: Failure to secure %fifork.ers' Cor�pehsation, cove rage 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 t ' he Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
a pplication.
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
-rhold 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 issbance'of such
permit, or cessatiory 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 representativ s of thisCity to enter upon
the above- mentioned prope"rrty for inspection purposes
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Signature (Owner/Agen
PERMIT# CONTPIOL#
BUILDING PERMIT Wo 12-079 4491
DATE VALUATION LOT TRACT
JOB SITE N
ADDRESS riji-040 EUSV�',N(110WEX DRIVE 774-061-002
OWNER CONTRACTOR I DESIGNER ENGINEER
JUAN & MAIlt-01.W1�11TA, INIONICADA' 0fi'-N1110E.R
49175 MUMS -CoMr
I -A QU NI -A CA 92751 CMTIEDRAL (,'rl'Y CA 92234
(619)327-1.4209 COO 3571
USE OF PERMIT
ESTIAIATED UOST OF CONSTRU FION
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SIJP,-T(Yf AL CONSIRIX.11110N ANDPLAN CHECK $30.00
LESS PRIE-PAIDPHS 10.00
'NOW
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FINALED INSPECT
-7 RECEIPT I DATE 1BY OR
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OPERATION
DATE
INSPECTOR
OPERATION
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
I
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection Z 7 Z
Encapsulation
Gas Piping 14(e.4�t
Gas Test
Applianc"
X7� 4��_ 4Z 7
Final
Final ILM
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)
COMMENTS: