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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions o
Chapter 9 (commencing with Section 7000) of Division 3 of the Business an(
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
533670 H f' L
Date �" �- ' x' 1• � Signature of Contractor !�� �' -•
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor';
License Law for the following reason:
( ) I, as owner. of the property, or my employees with wages as their sOIE
compensation, will do the work, and the structure is not intended or offered fo
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensee
contractors to construct the project (Sec. 7044, Business & Professional;
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 b)
Section 3700 of the Labor Code, for the performance of the work for which thi:
permit is issued. My workers' compensation insurance carrier & policy no. are
Carrier Policy No.
GOLDEN UAGLI', rN r_ 122174-41
(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 37 of the Labo
Code, I shall forthwith comply with those provisions.)
Date: /. -'37 – Applicant .0'� /� �l3
V�
Warning: Failure to secure Workers' Compensation coverage is unlawful an(
shall subject an employer to criminal penalties and civil fines up to $100,000, it
addition to the cost of compensation, damages as provided for in Section 370E
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 hi:
application.
1. Each person upon whose behalf this application is made & each person a
whose request and for whose benefit work is performed under or pursuant R
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 i
work is not commenced within 180 days from date of issuance of suet
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.,
correct. I agree to comply with all City, and State laws relating to the buildinc
construction, and hereby authorize representatives of this City to ente(upor
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �'J-'o r� Date
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BUILDING PERMIT PERMIT 7/
SN,3 i 2..1 till
DATE 12/22r!"VALUATION SJJ119.4") LOT TRACT
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101 SITE
ADDRESS .�j-•.1.1.� EL.�►Lt�ii>�tk Ii
APN y -
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OWNER
CONTRACTOR/DESIGNER/ENGINEER
y .( S,. I" �'(�( 11 Ir. T
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72-850 :iCalW1XiR A ROAD
39725 0AlltAND LANE, SUT'i7i C
PALM DESFWP C.`ANl 92264
PALM DFSJ' V CA 92211
(760)345.7186 CULff 1137
USE OF PERMIT
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mRECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Footings
���y_� g�
Electric Bond
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
Utility Notice (Perm)
COMMENTS: