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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ckapter-9 (commencing with Section 1000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class EX14,I), te
I 11, ;
3,
Dat3— )I -,� C Signature of C6ntract,.a&"4.P1
OWNER -BUILDER DECLARATION
I hereby aff irm 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).
( ) 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
on �7 ',wQrkfo which this
,��O
0
SAS, Vr Code, for the performance of the, r
p it is S Arl 1"I lk�e-40.%
erm y workers' compensation insurance ca rier Policy no. are:
Carrier Policy No. I
(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 Sectio3770'0 of the Labor
Code,-I.shallMh 'hcomp itN h 96 Rrovisicarn's, C,
.0 'y _.4 -
ADate. Applicanw,
Warning: Failure to secure Workert' 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 Bu.ilding and Safety
for a permit subject to the conditions and re st rictions 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 pursuaritto
any permit issued as a result of this applica ton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees,
2. Any permit issued as a result of this application becomes nYll.'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 i's
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representativ es of this City to enter upon
the above-mentioned propOrty. for inspection poses
fi4�
/Signature (O'wner/AgentYl��k Dat
PERMIT # CONTROL#
BUILDING PERMIT 909� 129
DATE 911-7196. VALUATION 'U.41owoo LOT TRACT
JOB SITE 5340-5 CTSEAHOWCA JIM
APN '7744W54R!
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
3,11M); tMEEININHOWT.It NiL
�6252 CAWLSBAD Cr.
LAL 00INTA 92251�
YUCCA VAL),VY CA 92284
6 J. 0YZ28-1672 CRIN 372A
USE OF PERMIT
ROCX W/25YR, &HINGLE,
L
V t.
E 5 T i INU V f E, i C OS11'. 0 V C( N": H UC 1" 0 N
VERM 1'r ME 8V M MA RV
R.RROOF:F11,133 101-00-4184*0 $30.00
4-1
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SUB -TOTAL CONSTRUMON AND PLNN. CIE. C K
xss vix-PAID rt�us
T OTAI, PE A' F1 E E'S D U. K N 0W
R
S30.00.,
A
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
p
L�gj:pt
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
Final t
Final
BLOCKWALL APPRO
POOLS -SPAS
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
Wity Notice (PermL_
COMMENTS'