9707-051 (RC)LICENSED CONTRACTOR DECLARATION
1•hereby affirm under penalty of perjury thafl 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 force and effect.
License.# Lic. Class Exp. Date
MT ijY �. A k� ,if��'g41�" j ,3
Date '- ,Signature of,Co`ntractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury 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 declaration's:
() 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 whicK.this'permit is issued:
( ) I have and will maintaln'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 Policy No.
rdn neeiob cop(This secne?meted if the permit valuation is for $1 Od.00 or less).
(y1}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' compensation laws of California; and agree that if I should become
subject to the workers' compensation provisions of Section 3700.of the •Labor
Code, I shell forthwith comply with -those rovisions.
Date: X i a,._:..j Applicants Gr d: f - rCC'11r: IL .ri
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 attorneys 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 off icers;.agents and employees:
2. Any permit issued as a result of this application becomes null and void if
work is -not commenced within 186 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 for inspection purposes '
f j J I
Signature (Owner/Agent �•��- cJr )ate Date �i�` F� ¢
• PERMIT
+ BUILDING PERMIT � � # CONTROL4k '
96
DATE VALUATION LOT •' ,��7J1 TRACT -
S:IS.Ot)1).00
JOB SITE
APN
ADDRESS
,PJ *vy'74yE M
OWNER
CONTRACTOR / DESIGNER/ ENGINEER
LA QUi'Ntk 4 OVNTY d1lua..
JACK. CL,ARK GENERAL CONTRACTOR
77-756.AVENUE 50
s4-350AVEN1DA ifERR.ERA.
LA QUMA CA. .2253
LA QIf1NTrl CA 92353 .
(760)56473511 ' �C&A 4115.
USE OF PERMIT
N�;E'i.� OR RAN(a )BLYNG - ADD Mi.SC CO - RIM M CRi.iNG - MSC
R af'�40DELING
VALIUA)"ION 1,. 35..Ut1C>.Qa.LS
�:�:, ,
C:i'LMATED CM OF C'ONSTI:tjt"'YION
35,IDt)i)•tlm
CFJiYL• 1T FEE 6U:fINIARJ.
PLAN CUH('.':3{.`FEE . 101-000 439-31.R $26605j":"
CCO[d:) rRUC ION FEE 101 000-.418-000 3 31?.00
MONO MOTION Va'- gGNiNs. 1.00-0.0U=241-000 $7:35
C? _.
Sif -1"UTt� C: D NS" !Z[7 ' 1'1Ot� .AP7T11�L? i Cl l'C
LESS PRE -'PAID FEES
$0.00
'TOTAL, PERMIT FEES DUE NOW.
$.130.40
RECEIPT
DATE
BY
DA E F LEED
077
INSPECTOR
INSPECTION RECORD,.-.' 1
'OPERATION
DATE
INSPECTOR
OPERATION:-!•
DATE
INSPECTOR
r 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
41F.A.U.
-
Framing
Compressor
:..Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls -
Party Wall Insulation
Condensate Lines
,Party Wall Firewail
'Exterior Lath
t
Drywall - Int. Lath
171701
Final r
Final
POOLS -,SPAS
BLOCKWAPROVALS
steel
Set Backs,
Electric Bond
Footings'-
Main Drain
r
Bond Beam
Approval to Cover
PP
'
Equipment Location
UndergroundElectric .
Underground Plbg. Test.
Final
Gas Piping.
•
PLUMBING APPROVALS
Gas Test
Electric Final S'
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure.
Shower Pans
OX for Finish Plaster
Sewer Lateral,
Pool Cover
'
Sewer Connection
Encapsulation
Gas Piping
Gas Test
.
Appliances
Final
%•
COMMENT S.,
r
,
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring.
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
.Final
'Utility Notice (Perm)