9903-170 (PC)tr - LICENSED CONTRACTOR DECLARATION
I hbreby•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
Signature of Contractor --- �=-- "
OWNER -BUILDER DECLA"R TION
I hereby affirm under penalty of perjurythat I am exempt from the Contractor's
License. Law for the following reason:
owner of the property, or my employees with wages as their sole:V
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
contactors to construct .the project (Sec. • 7044, Business &Professionals
Code) /
( ).J am exempf nder.Section ' B&P.C. for this reason
bate Signature°of, Owner,
WORKER'S COMPENSATION DECLARATION`
I hereby affirm'° Linder penalty of perjury one of the following declarations:
have and will maintain- & certificate of consent to self -insure for workers'
compensation,` as. provided for by Section $700 of the Labor Code, for the
performance of the work for this permit is issued.
Se( )' I'have and will. 'maintain workers' compensation insurance, as required by
lion 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:. -
Camer : Policy No.
a .
Cs�.tLin>��S bA.t'�E1is '. xd1'rC 3atfS33
(This section need not be completed' if the permit'valuation isfor°$100.0 or less):
„t'.) 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' compen§ation laws of California, and agree that if I should become
sub�ject.to the workers' compensation provisions of Section 3700.of the Labor
Cdd'e,' I shall forthwith comply with.ti�ose provision. - - """"
✓Date:' IC' jl Applica t'� --`' - --- "
Warning Failure to secure Workers' Compensa Ion 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.
12 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 permitAp cancellation.
I certify that-1 have read this application and state that the above;.information is
correct.;!f agree to comply with all City, and State laws relating'to the building
conskctlohi and hereby. authorize representatives of this City to enter upon:
the above mentioned property for inspection purposes. m+'
�Signature.(Owner/Agents--fir- Date- ), s
:. BUILDING PERMIT. PEFMT#
�fy'
DATE VALUATION. LOT�e� TRACT
JOB SITE
APN-
ADDRESS
77-IS4D VENUEJ5 _
.
a vl
OWNER - - -
CONTRACTOR/DESIGNER/ENGINEER .'
. L#1Q ,J6lV ♦.A COUN`Cl Y CLUB B ,.
C OUI—MY Cl.d.JB .t1WNID413 & .t3.C.TND
'77-750 AVTNUL-' 50
7480 JON1 DIUVE, SUrl-E 6
L.A. C,1ClINTA. CA, 42�9
PALM DESERT CIA. 92260
(its Y-i46 10 .. C.'BL 3827
USE OF PERMIT
NA'I to
`
" i8so S,i . P A. IO .i;,'OWR S'i'i�'Mi FRA V & F AMIC)
` E'.ntTffiJ,%A.XR..R' D 4-W.Y. OF C43J. STR'fIOIV
V.Ii;.@MOT ,49.1?;E SUMMARY
PLAN C14ECK PTM 101-Gild-439-318
(1"0NCT-PL.l1TirDN M.
S
r3 rRoNC i io'noN t az - CO:xa4 100-000-241:-000 $s. S7
SUB- (.)T.A,► CONFfRUC`TION AIND i''LA.N C3fiECl
$020.97
I..Ey�+ ';can -PAID FEE
$0,00 '
TOTAL 6BEid.tV I >t+ E.ii S OVE 3140 Y
$420.97
f�
+
4`
RECEIPT `" "
DATE
BV '`
DATE FINALED
INSPECTOR" '
INSPECTION RECORD
• ;'OPERATION
DATE
INSPECTOR
OPERATION
DATE-
INSPECTOR
.-BUILDING APPROVALS
-----------
MECHANICAL APPROVALS
Set cracks; 7
Forms &Footings
Slab Grade
s . �
N'� 7
�?
IL
Underground Ducts
Ducts
Return Air
-y
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
a Dryvwall - Int. Lath
Final
Final
POOLS'- SPAS .
BLOCKWALL APPROVALS
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.Unes
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
a'
Gas Piping " ..
Gas Test
Appliances .
Final
•
w
'
�1:�.
'
'-
y,
COMMENTS: t
V
-
.,.
Final
Utility Notice (Gas)
'."ELECTRICAL APPROVALS
Temp; Power Pole
Underground.Conduit
Rough Wiring'?
Low Voltage Wiring
Main Service
• Sub Panels
Exterior Receptacles.
Smoke Detectors
Temp. Use of Power
Final
tlay Notice (Penn)