9907-410 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed 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 # i .. •' Lic. Class P Exp. Date
�j to ,,i 17 1
�RSate Signature of.Contr ct11
or
+' OWNER -BUILDER DECLARATION"!`
I hereby affirm,under.penalty of perjury that lam exempt from m the Contractor's
License Law for the following reason: ;
( )-
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). „
( -) I, as owner of the. property,. Wlth lids' ul
contractors to construct the project (Sec. 1044, Business A. Professionals
Code).
O I am exempt'•under Section' - t• ;'B&P.C. for this reason
Date Signature of Owner f '
. Y
r,
+ e"
WORKER'S COMPENSATION -DECLARATION'
I hereby affirm under penalty of perjury. one o{'the follow infg declarations:
m
O I have and'.will.ainfain 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 requlred by
Section 3700 of the'Labor Code, for -the performance'of the work for which' this
permit'is issued. My workers''Icorripensation insurance. carrier& policy `no:•are:
Carrier ' Policy No '
•tvr ma• i rrn.K"� �., - 4e,7 ho rV,'iita!!n t �r
t91,f1.i.. L L.tSaAd„ ` - .. H!P-•J✓-tJ�lerer ``a. • .
(This section need not be completed if the permit valuation is for $100:00: or less):
O I certify that in the performance, of the work for which this permit is issued;
-1 shall -not employ any person in any manner so as to become subjectto the
Workers' compensation1aws.of California, -and agree that if I.should become
sub' ct to -the workers' compensation)y�'roVisions-of 'action 37006f the Labor
- P f ' 1 (, .
Coag; 'sha11 �o h ith comply with those provlsldi st,1 +
Applicant • Y `/ d i:i l j, �� i ,/ •3
Warning: -,Failure to secure Workers om
Cpensation coverage Is unlawful and
shall subject an.employerto criminal'penalties and civil -fines up.to $100;000;•in
addition to the cost of compensation, damages •as*prodided 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: re strict ions' 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 orlpu�suant to
any permit issued.as'a result of this applicaton agrees tb, & 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 riuli'and void if
work is not commenced within.' 180 days from datetof�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-props �,forinspection
%pjufrp}osas.
*Signature (OwnedAgent) a Date
BUILDING PERMIT FERMr
` �"�
DATE ! VALUATION LOT ' �"" TRACT 71
53
-
JOB SIT yt ry - -
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ADDRESS _�y�.97► '7 ``�,A', 8i�4.'6 ,_�`liRuil'.- _
-
APN
.. 6744-0B1-0.`4`1
OWNER'
CONTRACTOR / DESIGNER? ENGINEER',
e
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PALM DF:.SENCY C'A 912211
2-'NU4,f
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('760)345-262
USE OF PERMIT
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^..29,z.00 h}r, -
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RECEIPT
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
/-- Z -a Pj
F.A.U.
Framing
1- Z o .. lti
Compressor
Insulation
1 - t S -60
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
'L• LFC
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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
_ 3 — .2_-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer LateralI.,Pool
Cover
Sewer Connection
7
Encapsulation
Gas Piping
Gas Test
--L'1 —00
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 5 -Z
Utility Notice (Perm) , Zg'