9703-040 (PAT)LICENSED CONTRACTOR DECLARATION
it rider penalty of perjury t at I �..
��eby affirm u -;`h am licensed under.pyovisions.of
Chapter94commencing with §e6tion40b0):of Divisiori 3 of theBusiness
-Business and
Wofessiorials Code, and my License is in,full force and effect:
Licenge # Lic..dass 'Exp. Date'
V. Y
Date Signature of Contracto
OWNER -BUILDER' DECLARATION
Qw.
I hereby affirm under penalty Of 'Pe'rjur't .y hat I am..exempt from'the Contractors
License Law for the following reason:
1, as owner of the'property, or my employees with,wages as their Sole
compensation, will d6 the work, and the structure is not intended or -offered for
sale (Sec. 7044, Business ,& Professionals Code).
e .
1, as owner of thpropert , ani exclusively contracting with• licensed
contractors to construct the project (Sec.. 7044, Business A Professionals
Code). -
O I am exempt under Section.BO.C. for this reason
Date. Signature of ,Owner.
WORKER'S COMPENSATION -DECLARATION
i hereby affierri;unaer penalty . of perjury one of the. folloWin4g .declarations:
:. ec aration.s:
O I have and will maintain a..certif icate of consent to self -insure - for work6rs'
compensation, as provided for., by Section 3700 of. the' Labor. Code, 6r the
performance of the work for which this perhriit'is issued. .
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for, the performance of the. work forwhich'this
permit is issued. My workers' compensation insurance carrier.&. poli , cy no. are:
CarrierPolicy. No.
(This section, need, not be completed iftheperm 4 it valuation is for $100.00 or less).
performance, f
('-)'I ' certify that in the ormance, o the'work for which this permit is issued,
I shall not employ any person in, any manner er so as to become subject to the
workers' compensation laws of California,' and agree that ' if, ' 1, sh6u'ld i become '
subje . ct I to� the. workers' . compensation proviii66� . of Section 3700 of the Labor
Code,.I shall forthwith comply with,those.0 rovisioQ.,
N . t rV
Date: Applicant'. L0,AA_
Warning: Failure.to secure. Wo.rk6rs'..Compensatior -.0lawful'and
shall subject an,e'mp'loyer to criminal penalties and civil fines up to $106,006'. in
addition to the cost of compensation,jdamag6s as provided for in Section 3706
of the Labor Code, interest and aftorhey's.fees.
IMPORTANT Application is hereby made to the Dire.ctorof Building and -Safety
for, a permit subject to, the conditions and restrictions set forth on Phis.
application..
1. Each,person upon whose behalf this application is made 9 each person at
whose request and for whos6,6 enefit wor.k.is performed under,'.or pursuant to
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'if
work. is not commenced withiri 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 informaii,on 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-menii6ndd property-for,inspectidn pbrp6ses.
X
Signature (Owner/Arii-_nt):'\ k D9te
PERMIT CONTROL#
.-.BUILDING PERMIT
9703-0'40 4807
DATE. VALUATION. *LOT; '��TRACT 2
4144N JYJ 2.51
J06 SITE
ADDRESS 47-55081A MONT1,UO
APN
OWNER-
CONTRACTOR DESIGNER ENGINEER
LANNIMU1 D`11? VE
th, PE WA st"N' CON
P.O. BOOL, UP -31
-182,51'A f i QUit' CAN '91A
P.ALN1. RKINGS. CA- 92203
IRA L. N4 SPRINGS CA 92261
CaLlf 37917
USE OF PERMIT
J_44S.r-, PAJ10,�0Vt.A_
P0Rf,'YJN-V[70 S111
s. r11zV0W*
Mipuxrru) �Ca. 'a, OF coNs
-PRAWT
CO, WS'lRUCTRYN1.17031
-.0. 0-419-,= 1. (At
Y
N CIO, 1C.
$1 e 10,
SS J_1'rJA[L) T'
LJ
10.00
CRAUT FERS DUE, NOW
MAR
2`,O 1997_,%
RECEIPTw
DATE
BY 7 -DA
DATE FINALED ...
INSPECTOR
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 7
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
BLOCKWALI, 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
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: .
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