0009-036 (BLCK)LICENSED CONTRACTOR DECLARATION
Cn I hereby affirm under penalty of perjury that I am licensed under provisions of
1-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04W U) Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp: bate
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I-' 439904 CIO C291
o Z r- \./Date/ Signature of Contractor
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J_J F- 0 C) OWNER -BUILDER DECLARATION
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UJ UJ r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z-, 1, 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).
co I am exempt under Section -, B&P.C. for this reason
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C\J Date Signatur6 of Owner
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< WORKER'S COMPENSATION DECLARATION
0 Z I hereby affirm under penalty of perjury one of the following declarations:U-) < cc
F- 0 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL' compensation, as provided for by Section 3700 of the Labor Code, for the
,0 _J < _J, performance of the work for which this permit is issued.
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< have and will maintain workers' compensation insurance, as required by
-b 0 Section 3700 of the Labor Code, for the performance of the work for which this
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0)permit is issued. My workers' compensation insurance carrier & policy no. are:
Z CarrierPolicy No.
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STATE FUND 1322326-99
< (This section need not be completed if the permit valuation is for $100.00 or less)."
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I certify that in the performance of the work for which this permit is issued;6.
I shall not employ any person in any manner so as to become subject to the
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workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation?,rovision,�,of Sect*Lpn 3700 of the Labor
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Code, I shall forthwith comply with 0, W,
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/Date: L,20W Applicant
Warning: Failure to secure Worker'Compensation coverage is unlawful and
C071
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 Building and Safety
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 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 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 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, fo5'pepectio �p rposes.
v 21�
vsignature (Ow6er/Agent). Date
BUILDING PERMIT PERMIT #
DATE VALUATION LOT 0OW-036 TRACT
09/11/2",
JOB SITE APN
ADDRESS 78-1/10 VIAN.OX"A
OWNER CONTRACTOR/DESIGNER/EN INEER
MR GARY AU189, MWP" STRMCZYK
7 0.710 VJA SORMA 82.231 BA;Yr HIL ni, Or,
LA QLM4TA CA 92253 111D10 CA 92201
(760)347-0399 COLA 3225
USE OF PERMIT
MEN -M'( A L D TY1 WX H 0
6 n WALL 70, 00LIP
ESTMI Al" COST OF COMMUCTION
PERMT FAM &MMMARY
3k
CONOWRICTION FU 101-000-4-18-000. $41,00
SUB-WYM, CON MRUM109 ANDPLAN CHECK $41.00
LMS PR&PAIDFM $0.00-
TOTAL FrOLNUT FES DUE NOW $41.00
6X ty es�p
RECEIPT DATE,13Y
1.ATE FIN'ALtD LINSPECTOR
UV
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
3 s
Main Drain
Bond Beam
.00
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
. po I 5-r
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
COMMENTS:
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)