9906-083 (BLCK)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I-_ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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C14 LLJ Professionals Code, and my License is in full force and effect.
C,) License # Lic. Class Exp. Date
CY 6341111
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Signature of Contracto( 11.4 P
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CD OWNER -BUILDER ECLARATION.
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W W I hereby affirm under penalty of perjury that I am exempt -f rom the Contractor's
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co License Law for the following reason:
Z ( ) 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 & Professionals
Code).
I am exempt under Section B&P.C. for this reason
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C%J Date Signature of Owner
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< WORKER'S COliPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LO �< CE -insure for workers'
- 0 1 have and will maintain a certificate of consent to self
X LU LL compensation, as provided for by Section 3700 of the Labor Code, for the
0 _J _J performance of the work for which this permit is issued.
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< I have and will maintain�workers' compensation insurance, as -required by
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LO <� ectibn 3700 of the Labor Code, for the performance of the work for which this
0) permit is issued. My workers' compensation insurance carrier & policy no. are:
,�J- Z Carrier Policy No. f
c b 5) GOLDEN rltkOLE INS. 'N NV C 4 8 7% -6 - 02,
< (This, section need not be completed if the permit valuation is for $100.00 or less).
_J ( ) I certify that in ihe performance of the work for which this permit is isked,
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 1phoold become
. - .11
s�pject to the workers' compensati�Nh provision—f-section' 3,700 of the L�68—r
so
rode I shall fcpWith comply(with, tl�6se pr6isions.
hate kpplican
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subjectan employer to criminal peAlties'and civil fines upto$100,000, in
N-1
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 L6 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, apd-bereby authorize represeffatives of this City to enter upon
.. ) .7 ; I
/thbove-me4tioned propertyrfor-inspection purposes...,
A 17
S, t . '_ I' - - J 'I -
Signature (Ow!ne�r��e6t)' � A� ___ _12)ate
'At 44._
PERMIT#
BYILDING PERMIT
.)OVALUATION S400.00 LOT TRACT
DATE 06/11/14
'S B SITE _K110WER
Al oRSS 270 ELM
T
CONTRACTOR / DESIGNER / ENGINEER
C 0 R 0 NIF, L C 01 NN In. 11, L, C I I I DIN 11
CORONER" 1C()N111�1'R1U111M0_ N
51-540 EISEINIHOWER D&
51-540 EISENHOWER M
LA QLPINTA CA 92253
LA QUMA CA 92253
(760)564-4604 CRL# 2261
USE OF PERMIT
25L.F. 4Rh-T WALL
4 17, WALL LF
POW"17 FER SUMMIARY
CONSTP,UC310N F93 loimo-418-") $15.00
S03-TOTA!, C
'0NFrFkUCM1QN ANON -AN CRECK,
$0.m
LESS PRE -PAM FEES
$0.00
TMALPEMMIT VER'SOUE'NOW
SI&OO
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
0
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
0. 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
4
Underground Plbg. Test
Final
Gat Piping
PLUMBING APPAOVALS
Gas Test
Electric.Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out —
Equipment- Enclosure
- --- ----
Shower Pans
OX 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)