9902-038 (RC)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
Pr6fe�isionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date: -Signature,.of Contractor
ti OWNER -BUILDER DECLARATION
I her ' eby affirm under penalty of,perjury that I am exempt from the Contractor's
License Law for the following reason:
1, 1 as' owner of the property,, or my employees with wages as their sole
compen - sation, will do the work, and the structure is not intended or offered for
saile-(S�6c. 7044, Business & Professionals Code).
1_ as,owne'of the. property, .arn exclusively contracting with licensed
Contractors to construct. the pioject (Sec. 704.4, Business &,Professionals
Code) 4`.-
O rami'exempt 'under Section B&P.C. for this reason
Signature of Owner L -V P
,Ddi'e . -, 2" 't /,-; , d /' -
L " '
WORKER'S COMPENSATION DECLARATION'";
heire6y affirm under penalty of perjury one of the following declarations:
have and will maintains certificate of consent to self -insure for'worke�§'
or ripensation, a s I provided for 'by.Sectio n-3700 of the Labor Code, for the
performance of the workforwhich this permit is issued.
have and will maintain workers compensation insurance, as required by
becti6n 3760 of the Labor,Code, for- the performance of the work for which this
e6if'is issuea. My,.workers' compensation 'insuraince carrier & policy no. are:
Camer Policy No. '564 . I r, 5, 01 7
W c (0 B
(Ti16/fil
(This not be completed if the permit valuation s or $100.00 or; less).
1 cerfiN that in the performance of the work for which.this permit is issued,
I s hal I 'not'em ploy 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 ubjb6t.toL the'w6rkeri' compensation provisions of Section 3700 of the, Labor
C , :,
e;: I shall forthwith comply with th6se provisions)
J)ate: - Applicant' f 1,. Jj
Warning: Failure to secure Workers' Compensation coverage is Unlawful and
shall subject'an employer to criminal penalties and civil fines up to $100,000, in
;addition 16 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 1
ior,,,, a., permit subject; tothe conditions .and restrictions set forth on his -
application.
Each person
rson upbn whose behalf this application is made &L each person at
c p i
hose request and for whose benefit work is performed under or pursuant.to
,w
- y p0im it sSU:
an n d 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
s 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
-onsiructi
pn,.and hereby authorize representatives of this City to enter upon
fhe
aJove -mentioned property for inspection purposes.
-(Owner/Agent) 2' ate
n— D
r
g� al.a
BUILDING PERMIT PERMIT#9.902,038
DATE,�, VALUATION LOT TRACT 'V4
JOB SITEAPN
ADDRESS 550�200 A
OWNER
CONTRACTOR DESIGNER ENGINEER
St . K'"u-PISER T UU S101r.rST11.1c
�W-4P9.E1Sr-.,N*H0%VCR DIUV6
1A Q NTA 91253
USE OF PERMIT
CIONWFIACIA REMODEL
UXPANZJ) PRO 8H0N7tGTAJL WITH GLASS
'PEIRMAT YBI El SUATKARY
K,AyN C-11ECK FT46 t01 -M-439-318
E'1$1r3=tCAL to't -Wo-4121.0-ow =550
1,'v9Y.H0N- h3,C - QU�Qvf 100. 00.4`11 X000 $17.85
f1CffVf(YFAL C0.'Nr,-`,rRUCM()N AND PLAN C14FCK'
L= PP,&.PAtD FEES
$0.00
4; OVE
RYCAL PERMIT V FG NOW
IN %\[DATE
I RECIEIPT/1 l�
1 BY
DATE
7,AL
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 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
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
Neater 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)