9809-110 (BLCK)LICENSED CONTRACTOR DECLARATION
I�hereti-y-affirm under penalty of perjury that I 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,
I6 £i C'., .g �I7'A 00
iDat l- Signature of Contractor
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 declarations:
O 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.
I have and will maintain workers' compensation insurance, as required by
S ction 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:
Cartier . o r . Policy No.ISMON
(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' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
�`de, I shall forthwith comply with those p ovisions:
'Date: A! t r/j10. Applicant- % � t �j1.; J.
Warning: Failure to secure Workers' Compensation'coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work, is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the
above-mentioned property for inspection/purposes. --
gnature (Owner/Agent) � :I/. � l/`/}- /,�/Date •y�
/ } :1
PERMIT # CONTROL #
BUILDING PERMIT 9-N9-110
qq 1
DATE 9 �719$ VALUATION S4,0110.00 LOT TRACT
JOB SITE 77-750 AVE. 50
APN - C
ADDRESS
_
L -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
77-750 AVE. 50. � ,
•7-165 SEL. tllid ROAD, ;Piki.,M DESERT
I.,A Qtllt'N'IA.. CA 92253
LA QUINTA GA .92253
f 7c5(1}3t1:5-lei 3 C ti.tr 1.631.
- -
USE OF PERMIT -
6FINETtE1.I.. SUII.i).iNG
160 L .r. HLOCK WALL M.011 ORCO !PYS' FIA
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OFT. WALL 1.60,00 Li
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]LESS ICI F-PA1:D FIEFS
$0.01)
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�3.316
RECEIPT
DATE
BY ,+p
DA F ALED
INSPECTOR
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INSPECTION RECORD
-
c '._OPERATION
DATE
INSPECTOR
OPERATION
DATE ..
°INSPECTOR
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_
1
BUILDING APPROVALS
"MECHANICAL APPROVALS''
-
Set Backs
Underground Ducts.
-,',,Forms
'
,,FormsAB Footings
Ducts
'
Slab-Grade
Return Air,
Steel:.::
Combustion Air; , .
r
f'
Roof Deck
Exhaust Fans _
erg'`
: O.K_to Wrap
F.A.U.
Framing
Compressor ' -
" .ti.
Insulation
Vents
r
Fireplace P:L.
Grills
Fireplace T.O.
Fans &Controls
F
Party;Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior. Lath
,t
.Drywall`-1nt. Lath
F,
c,
Final 7..
Final
c�,
POOLS ' SPAS:' '
k
�a BLOCKWALL APPROVALS
p
steel
'Set Backs.
Electric Bond �: "
t
"
r
=Footings,
Main Dram
,
r
Bond Beam
Approval to Cover
s•
Equipment.Location
r
Underground'Electric
t
Underground Plbg. Test; '
Final.
-
Gas Piping':',=
�• a-
�s
n PLUMBING APPROVALS
Gas Test
Electric Final
..�
y
Waste Lines
Heater Final
Water.Piping
Plumbin Fina I .
-
PlumbingTo Out
P Equipment Enclosure
F, Shower Pans O.K. for Finish Plaster
'Sewer lateral Pool Cover
Sewer; Connection Encapsulation
Gas Piping
Gas -.Test
.Appliances
r Final
COMMENTS:
Final,
Utility Notice (Gas)
-'
ELECTRICAL APPROVALS
t -:Temo":Power Pole �
Underground Conduit
a .Rough:Wiring
r
Low Voltage Wiring
Fixtures
.> zMain Service
E ° `Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors "
Temp..Use of Power
r Final . 1
Wtility.Notice (Perm)
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