9906-167 (RR)LICENSED CONTRACTOR DECLARATION
I heFeby affirm under penalty of perjury that I am licensed under provisions'of
Chapter 9 (commencing with Section 7000) of Division3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
235 717 - G39 � �3 tr"2fSi
D ,t 271-.1f Signature of Contractor --Z a/
OWNER -BUILDER DECLARATION
•1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:.
( ) I, 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, am exclusively contracting with licensed
contractors to construct ' the project (Sec. 7044, Business & Professionals '
Code).
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION,
I hereby affirm under: penalty `of perjury one of the following ,declarations:
() I have and will maintain 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 required by
Sebtion 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
.! A t 1. i dcS �•'lisvJJ (This section section need'not be completed if the permit valuation is for $100.00 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 of Section 3700 of .the -Labor
Cold, I shall forthwith comply with those•prov.SID S. ,
ID fe: /' -Applicant z .% /`�./
. ....
Warning: Failure to secure Workers'. Compensation coverage is unlawful and
shall -subject an employer to criminal penalties'and civil fines up to $1,00,000; 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 applicator 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 for inspection puurrpos S.
Signature (Owner/Agent) ' -°,/Z✓- ` Date—/—,
BUILDING - PERMIT PERMIT9906-167
DATE06/,`$2,/,,1•"VALUATION. $4,7; 1.00 ' LOT TRACT
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JOB 2 Yp
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APN -
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LA"rLTi �'4 b1�? I>f!'A.t3Z
UMSTE-1t.;+1 Q AICIF IC 12OGF1l1.1c
48-10(i IVV.FA LACUONA
34162 LA CA.1I'NVNi A WAY
LA QC71WVA. CA 9N53
PALM SPRINGS CA 92262
(760)416-5M CIBI-A 41293
USE OF PERMIT
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, 417moor!
4,721.00
:FER 10J-000-4,18-000 $300i
$UB-•rO L.C.ONS'F'WXrlpAi.ANT�
U1,Sc Rtti •-PAID FEES
$000
.I i1"�1�1. ;'1'.IILi1`' '�+ �';!!i DUE:h901V
1+>�11.€fi!I
F�iECEIP jj�
DATE
�.71
BY. r I
DATE FINALED
INSPECTOR
r ..�. M - J. -. +•Wit! '_r.'-V.wE"+.�.-111w:a :'.'- +i•'� _
M1 •
A '
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 TO.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
DryWall - Int ath
Final
Final 6 / O
BLOCKWAL A PROVALS
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: