9906-160 (BLDG)LICENSED CONTRACTOR DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
NW Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
d *33717 G-39 p;iliZtii
LU
oZ r—ate f ` Signature of Contractor'
co0P�_
J U C:) OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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
L
N Date Signature of Owner
ON
rn
Z WORKER'S COMPENSATION DECLARATION
LL
C:) 2 (X:
I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q C) ( I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
'IT Z Carrier Policy No. 0cb 42
-tlM,
J(This 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
worker (compensation laws of California, and agree that if I should become
3 subjedt to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions•
Pate: ". ; f 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.
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 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 forinspectionpurposes.
Signature (Owner/Agent) �� %'fi t, d'�•� Date' c i -1
BUILDING PERMIT PERMIT#
DATE {W#22J�99VALUATION $13.441(10 LOT TRACT
JOB SITE
ADDRESS 48--126"U CA1.,LE S13.+�°1.MAN APN _ d
OWNER CONTRACTOR/DESIGNER/ENGINEER
Ya ulTr fk er.,\1.i1A (Y 7, GMYx`a1
48- WO `v'15"i'A LA GUNA GUN3452 LA. OUVIPANA WAY
Lrl QU]N'm CA. 92253 PALM SPRINGS CA. 9n62
(YiSt?;t 6-5977 C -BL## 4291
USE OF PERMIT
08NURAL BUILDING
ift&ROO
reaZOOF 13,442.00 LS
,FS LAMIMI D CM. OF CONS sRR'Wf 10N, 13,442.0
PERAUT F E.R. SUMMARY
REROOF FESS 101- t)-418-Fl{?(i $30100
LESS PRE'41"Al-D FEES $0.00 .
RECEIPTi , DATE _ _, BY' DATE FINALED INSPECTOR
f'
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 T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
D,91waII - t. Loth
AOL
Final
Final Z
BLOCKWAL 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 Voftage Wiring
Fixtures.
Main Service
Sub Panels
Exterior Receptacles
G'. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
r
LICENSED CONTRACTOR DECLARATION
J hereby affirm under penalty of perjurythat.l.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:forbe and effect.
License #, Lic. Class Exp. Date 1�t
3,5717 C49 01/ V2011
ate ` Signature of Contracto
OWNER -BUILDER DECLARATION
I hereby affirm under penalty ofperjury 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).
( ) 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.
(4 1 have and will maintain workers' compensation insurance, as required by
SdClion 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.
S R A L D 14Fa2 t3
(chis section need not be. completed if the permit valuation is for $100.00 or Jess).
() I certify that in the performance of the work for which this' permit is issued,
I shall notpmploy any person in any manner so as to become subject to the
worker ' ompensation laws of California, and agree that if I should become
subj9d to the workers' compensation pro isions of Section 3700 of the Labor
C e, I shall forthwith comply with tho prove ,Kate: "' ? r 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.
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 9f such
permit, or cessation of work for 180 days will subject permit to da-tP61lation.
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 ab6ve-mentioned property for ins' ection purposes.
y..
gig/nature(Owner/Agent) �� ' %` Dates ✓%
,BUILDING PERMIT PERMIT# ` _ -
• : • '. .' '.
DATE O►��a2�'! .VALUATION 5193,442.00 LOT TRACT'JOB
SITE
ADDRESS 48 -IU U .LE SERANAS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1 AGUTN,�V2I A fPA7
a,i ��t �x isr� nt
Tt DAiPACT., D t
rruv a �.s�+C a.uiia
46- iOO VISTA Lir► GUNA
3402 LA CAMPANA WAY' .
LA QWNTA CA 92253
PALM SPRINGS CA 92262
(70)416-,S977 CBTA 4293
USE OF PERMIT
GENE",, Bi.i`1LDIW
RE -ROOF
1MOOF 13,442.00 LS
OTLAAATNED CM OF CON;TRUCTIO.1
A3,4»32,
ii'ERt1i3 T FEE SUMMARY
IREROOF FIM
i
r
tl& 11: C� 1CTil7N t NTY$34.00
LESS PRE -PAID FEES
$0.00 -
TOTAL .PERMIT FEES DUE NOW ..
1"0.00
+IECEIFT
DATE r
BY ^'' �-!
DATE FINALED
INSPECTOR