9704-082 (BLCK)LICENSED CONTRACTOR DECLARATION
U) 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
CV W Professionals Code, and my License is in full force and effect.
O CV) License # Lic. Class Exp. Date
O Lo -W/584 13 C - !U
ZO n
_
Date q—r)1"' 1 Signature of Contractor
T
co � o) OWNER -BUILDER DECLARATION
UJ W I hereby affirm under penalty of perjury that I am exempt from the. Contractor's
~ U) License Law for the following reason:
Z ( ) 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).
C'') ` () I am exempt under Section B&P.C. for this reason
LID
N Date Signature of Owner
ON
rn
d Z WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
U-) O () 1 have and will maintain a certificate of consent to self -insure for workers'
X UJ compensation, as provided for by Section 3700 of the Labor Code, for the
O _ Q performance of the work for which this permit is issued.
C0 Q U �. I have and will maintain workers' compensation insurance, as required by
Q LO Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
O LcCh, )IN BAC IX ,INW�, ;D6110."�
J (This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance 9f the work for which this permit is issued,
1 shall not employ any person in a�ryyimanner so as to become subject to the
workers' compensation laws of Ca11mia, and agree that if I should become
3subject to the workers' compensatioA provisions 6rSection 3700 of the Labor
ode, I all rt y¢ h comply with those provis�lon�._w____
V"CDate: _4 Applicant ;
%
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 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: t-
1.
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 foV80 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/a rCity, and State laws relating to the building
rstruction, and hereby authofize representatives of this City to enter upon
above-mentioned propert or inspection pu`r'poses.
Agnature
Sfre (Owner/Agent) rm�'�� ''^��
---�.---sate
BUILDINGPERMIT' PERMIT# CONTRCOL#
/V=1 PERMIT
J ®®
DATE. 411797 VALUATION $7.720.00 LOT TRACT
JOB SITE
ADDRESS .� K{1 P11,'H+ HLt, MM'31
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
w k� 6 4t l pi.4'
A, & i< 1 COM . UrCDON
i5-430 PE8.8U' 8EiWH
78-070 CALLE CADIZ
1.A nLlINTA CA.
T ik C,3r_7KIM CA 922S3
f7Gf1) 4,dR3A Ci i:i€ 676
I ISF OF PERMIT
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�3G4t 621 ,�si9'drst>�vaiii ulld,1503 or4ft P
'ald.ev wstil usccJ IaystGnt
0 4-T. 4 Al''L. .20.00 LI
•I V'r. 'WALL 45.09 Ll.?
72 0.f0
(X)N18'IWVC7I'l0N 03KE 101.000-418-0(?() SVl C
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�IX'710N AND '?AN CH!CK
ST?ppETAItE^
MOO.::
t
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
BLOCKWALL 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 APPROVA S
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
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: