9903-180 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter,9 (commencing with Section 7000),?f Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
'License # Lic. Cl Exp. Date
Date, Signature of Contrabt r
OWNER -BUILDER DECLARATION
I hereby'affirm under penalty of perjury that I am exempt from 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).
1, *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,
l.hiave 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
Section 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 y. Policy.No.
-S, h 7A 9' 3
(This section need not completed if the. permit valuation is for $100.00 or less).
()Of,certify that in th6 performance of F Work ior which this permit is issued,
I shall not -empl6y any person any y
N
f Calif
so as to become subject to the
workers' Compensation laws o ahf,?rni"a, d agree that if I should become
t,, 0
subject to the'workeirs' compensa roi:inons of Se,�ion 3700 of the Labor
Code, I shall forthwith comply with t6y�sv
ate: Applicant
1. /
W6rni g; Failure to secure Workel. Compensation coverage is unlawful and
phall'subjectan employ'e'rto 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 conditio6s and restrictions set forth on his
application.',
'1; Each person upon, whose behalf this application is made & each personat
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, indemnity
,&.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 commence) within 180 days from *date of issuance of such
permit; or cessation of work for 180 days will subject permit to cancellation.
I.c.ertify that I have reatDif application and State that the above information is
correct. I agree to co qfwith all City, and State laws relating to the building
Construction, and hyr 6y authorize representatives of this City to enter upon
the above-m'enti _ 7c o erty for infection purposes.
re (Owne ,Agent Dates 1 1—f —1
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT'
3/17/99 S 5, 7M). 0 0
JOB SITE
ADDRESS S.720.M5LE HEM.A
OWNER CONTRACTOR/DESIGNER/ENGINEER
M. CARL A & M C011,I&IFRUCTION
55-1720 PEUSLE M k0l 78-070 CALLS CADIZ
LAQUINYA CA 92253 LA QUI NTA. CA 92,2531'
CRIA 626
USE OF PERMIT
DO LF. JK' 4',rL-210 LF7 X 18 N N OCK WALL - ORCO 9 IMIM
6 r7, WALL
250.06 1T
9STMATED CMT OF
PERMIT FEE SUMMARY
SUB-TIDT00, CONSTRUC7110NAND RGAN CHEM ULM
LESS $0.00
TOTAL PE RMIT FEEN OU E NOW
A/
RECEIPT DATEBY
17 DATE FINALIED _JINSPECTOR
INSPECTION RECORD
41 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
Framing
F.A.U.
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 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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: