9606-023 (BLCK).LICENSED CONTRACTOR DECLARATION:
I hereby Affirm under 'penalty of perjury 'thaf I am i1censed Under provisions Of
Chapter 9 (commencing with Section*.7000) of Division .3 of the Business and
Professionals Code, and my License is in full force" and effect.'
License # Lic. Class Exp.,Date
1* 9l
Dam Signature of Contractor�
OWNER -BUILDER DECLARATION J
I hereby affirm under penalty of,perjury that I am exempt from the Cont4ctor"S
License Law for the following reason:
1, as -owner o'f'the property, o . r my -'employees with wages� as their, - 6616 -
compensation, will do the work, and the Structure is not intended or offered for
sale (Sec. 7044, Business & Peofessionals'Code)..
1, as owner of the property, am exclusively contracting with .l'icense'd
contractors to.construct ,the project (Sec, 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C.Jor this reason
Date Signature of Owner
`WORKER'S COMPENSATION DECLARATION
I hereby affirm under, penalty of perjury one. of: th�e,followingdeclarations:
I have and will maintain a certificate. of consent to self -insure for workers'
compensation, as provided' forby Section 3700 of the Labor Code, for the
performance of the work for which this. permit is issued.
JI), I have and will maintainworkers' compensation - insurance, urance, as required by
Section 3700 of the Labor Code,, for the performance -of the work for which this
permit is(qsQqq1jk4k4workers' compensation, insurance carXieWvip.' i6y no. are:
Carrier Policy NO.
OP,
(This Section need not be completed if the permit 'valuation is for $106.00 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
s o . f Section 3760 of'the.Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation
coverage is uhlawful.ind
shall subject an employer to, criminal penalties and civil fines up -to $100,000, in
addition AD -the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
Z
IMPORTANT Application is hereby made to the Directo . r of Building.aQd Safety
for a permit subject to the conditions and restrictions O'sei forth on his
application.
f"Each person upon whosii behalf this application is made &,each per , s . on,at
whose request and forwhosebenefit work -is performed underor 'pursuant to
any permit issued as,a result I of this ap'plic6ton agrees to, &-shill, 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 if
work is not,commeh.ced'-within.180. days t from. date of issuance ce of such
p6rmit,'or cessation of work for 180 days will subject permit to cancellation.
I certify that'l have read this application and state t.hat'.the above information, 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 propert r for inspection purposes.
n�y
p
,Signature'(Owner/Agent) wd Date
BUILDING PERMIT'PERMIT# CONTROL#
.
9.6Q64)23 3447�
DATE VALUATION .LOT: TRACT
6/ 5/916 2,22 -5 -AQ
JOB SITE
ADDRESS 47-4.AS VIA YLORENCE
TAPN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C
LANMAU DRV. O
'UN CON -91'P `110N
iMPERIA"L. AK,
P0 Box I '123.
2825 frmiQu rrz c ON NDI
PALM SPRINGS'
PALM SPRINGS "".CA 9.2263
7'7743{1_;
, (6,f 32&1277_. CEL4, 3797
USE OF PERMIT
GENERAL Wit'07ING
TAN FT 6-F -51;7 61'K G ARIDEN WAU;
3;;, AILTUAT RD COSM Of CONSTRUMON'
22A 00
�UQKX MUCTIO N 01-E, • I(H-0)-418-004) $54,00
SUB-Tibl'At COMMUCTION.A.M) PLAN C1 PECK
I LESS P -P
W -PAID. FESS':
.$54.,00
D -AT; i4mMuf rf,,ms D.Uri., NOW
YC
$54;00
RECEIPTDATE
.1.
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
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 3
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: •