9801-023 (SFD)LICENSED CONTRACTOR DECLARATION
U). I I hereby affirm under penalty of perjury that I am licensed und& provisions of
1-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and'
04 W Professionals Code, and my License is in full force and effect.
O Cn License # Lic. Class Exp. Date
r- LO 67074 lio
r- W
ZDate
r- Signature of Contractor
CID 0
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r- j:= OWNER -BUILDER DECLARATION
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W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
131 -
License Law for the following reason:
their Sole
Z 1, as owner of the property, or my employees with wages as h
compensation, will do the work, and the structure is not intended or offered.for
7ndd, Risiness P, Professionals Code).
1, as owner of the - propert . y, am exclusively contracting with lic6nsed
contractors to construct the project (Sec. 7044, 'Business & Professionals
Cocle).'
V)I am exempt under Section B&P.C..for this reason
LO
0 C\1
C\1 Date
of Owner
Or)
WORKER'S COMPENSATION DECLARATION
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0 1 hereby affirm under penalty of perjury one .of the following declarations:
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1.- 0 1 have and will maintain a certificate of consent to self -insure for workers'
X LLJ LL compensation,! as -provided •for by Section- 3700-of,the Lab6r Code, for the
m_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
C5 () U-) Sebtion 3700 of the Labor Code, for the performance. , rmance. of the work for Which this
Il�5 permit is issued. My workers' compensation insurance carrier &.policy no. are:
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� _Z Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
1-,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 e
workers' compensation laws of California, and agree tha ' Liffshoul;4� be -come.
!subject to the workers' compensation provisions of Sectio"n 3700 of -the Labor
Code, I shall forthwith comply with those provisions.
VDate: 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'3766
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and S�aiefy:,
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 oV 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 informatio , n 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 inspecti5—n-p-drooses.
Zi nature (Owner/Agent).-1 A Date 7.1" 1 7X'/4
PERMIT# CONTPOL#
BUILDING PERMIT
DATE VALUATION.: LOT-. t TRACT' '016`8:0
.
J
JOB SITE
161-9iW 14A. CAMUM
]APN
ADDRESS
OWNER
CONTRACTOR, DESIGNER / ENGINEER
.r. D, DESE R' -f -DE, VIP, LOPME N97'
C,,'0hfS'. T.R.1)(17110111
P .0.11t3 1146
'7924 N
LA QUINTA, CA 9225.3,•-
.1.',A. QUI NM CA. 92253
.199
USE OF PERMIT
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C4�STMICMNS TMUCTION '31035-00 Sr...- - JAN
1'5 1998
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ON, -RUM-10IN
V52,793 90)4.
PLAN It C K., FEEZ
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10[ 4(?U-Qt7-Q00 $190.89.1.
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ffff AL-Pul RIMIT VICIEIN Oul", NOW
57,566; -73,
RECEIPT
DATE
BY'/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OFF -RATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs —
Underground Ducts
Forms & Footings v -
Ducts
Slab Grade v A641C
Return Air
Steel
Combustion Air
Roof Deck 4-1-12V
Exhaust Fans
O.K to Wrap
F.A.U. -
Framing (oC
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 U-
Final
Final
BLOCKWALL APPROVALS
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 ell
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)• ri SILL
COMMENTS: