9910-022 (BLCK)LICENSED CONTRACTOR DECLARATION
L 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
C1I W ' Professionals Code, and my License is in full force and effect.
C) License #f Lic. Class Exp. Date
UJ
Z LDate Gr / �' Signature of Contract,<----"� "
coo O.1�
J U C:) OWNER -BUILDER DECLARATION
HWd I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a 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).
CY) () I am exempt under Section B&P.C. for this reason
LO�.
C\1 Date Signature of Owner
p CV
Q WORKER'S COMPENSATION DECLARATIONCL
'
C) 2 Z I hereby affirm under penalty of perjury one' of the following declarations:
p () 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 1 have and will maintain workers' compensation insurance, as required by
QU Q Section 3700 of the Labor Code, for the performance of the work for which this
LO H per is issued. My workers' compensation insurance carrier & policy no.'are':
? Z Carrier Policy No.
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
workers' ompensation laws of California, and agree that if I should become
subje t to the workers' compensation provisions of Section 3700 of the,Labor
C�o�e, I shall fokhwith comply with tho e -provisions.
VDate: 01,-,1,41_ /r1` Applicant
Warning: Fa lure to secure Workoff 04ensation 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
V* 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 thst-I have read this application and state that the above information is
correcteol'agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
th above mentioned property f T inspection purposes.
Y f
Signature (Owner/Agent) Date f
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PERMIT #
BUILDING PERMIT�s��
DATE 1j)JI84J11 "VALUATION
51,1511.LOT 15, 16 TRACT 1x97, U27JOB .
ADDRESS 14-200 E11.13 `,�eN+YlT1���I VI MOVEAPN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
"N'IC'1�4�7�,t1�i,/l�ERS
AiTt^;t'(�7). ASAKi'i4k:i
` 45 S. &i143.UMO.0 -
. . .
745 S. h+9:AREN w0
PAS .ADE A
i°Vii. 91:106
P..tiSA.iJFNA
CA 91106
f,626094-4944
C"1:1,A 5724
USE OF PERMIT
74 LF, , 1 1E i, t\(NWK LVFi11. CIT' STiUOI ARD
5F7. CALL
70.00 L
PERMiT FEE $UM.iorsARV
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$37 til}
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RECEIPT
DATE
BY
DATFAINALVID
INSPECTOR
INSPECTION RECORD
OPERATION'
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air 4,
Steel
Combustion Air
,Roof Deck
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
PartyWall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Ai,
A
Final
Final
POOLS - SPAS -
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings 7Z
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final cIry
Underground Plbg. Test
Gas Piping
j
PLUMBING APPROVALS,
Gas TestElectric
Final
'Waste Lines
Heater Final I. X
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans t
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
f
Appliances
Final
COMMENTS:
Final.
Utility Notice (Gas)
ELECTRICAL APPROVALS 0
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)