9911-061 (RC)LICENSED CONTRACTOR DECLARATION
I hereby 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.
Licensees# �L^iic. Classy q Up. Date
.. ^1'7,�""""*!Hwy.'+r-�•1PMSri^9�S.a....�....r....�:...;.•�;,..,�„��^'
Date 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)."
O a'h exempt under Section B&P C. ,for thisrreason
0a"te' t.l `S 't ( Signature of Owners •a+,.. 7,•.
WORKER'S COMPENSATION DECLARATION -
I hereby" affirm under penalty of, perjury one of the .following declarations:
() I have and will rnaintain.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
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.
(This section need not be completed if the permit valuation is for $!00.00. or less).
( j,J 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 shall forthwith comply, with those provisions
ate:' 1 k P l 113L, Applicant° cr ;., . w;,- . ; '� •,r•
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an *employer to criminal penalties and civil fines up to.$100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of *the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director.of Building and Safety
for a. permit subject "to "'the conditions and restrictions' set forth on his
application.-
1. Each person upon whose behalf this application is made & each person at
whose request and for whose -benefit work is performed under. or pursuant to
any permit issued as a result of this. applicaton agrees to, & shall, indemnify
& hold harmless'the City of .La Quinta, its officers, agents and employees.
2. Any permit issued as a result'of this application becomes null and void if
work is not commenced within ,180 days from' date'of issuance. of, such
permit, or cessation of work for 180 days" will subject permit to cancellation.
I certify that I have read this application and state- that the above information is
correct. I agree to comply with all City "and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above -mentioned property for inspection purposes
VSignature "(Owner/Agent) S.1 c t+a° ~ s' _r ; .'a~*z-"':E Date'1 ti .
PERMIT #
BUILDING.PERMIT.�4�
DATE Cl
'" VALUATIONa$ LOT TRACTJOB
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SITIf
ADDRESS , T7-7-5 t�r;VENIRE so .. •
APN . ; � V'
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LA. QUI. TAC',00M YC LUB
t WIt..D;":d. :
77-750 A dL�I�t(M Y) . .
' LA. Q IINTA 92253
,
L�f t.L,f 4mee pg,! HAtf_ hC'41 L 11
USE OF PERMIT
tJa,`�
SUPPMiblc..lvTAL TO PAS16 c.°€,WR PMtvfi f #49%Ct.3k ro "to.
VA€.ii"$'i`I{)i',i 101it{{'st} fi LS
PERMIT FEE SIUI NA—Wir
0,0CiFttCAL FEE i:d19,1Tt��4'2t?-fJFaf,) �?t�t.�t�
FaT RMAR IG _> s 10 4.ANO-419-MD;3
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SU„`�!,-TOTA.}.i C',aii6f G'° l RUCT LOle,,A]ND PIJ+'')+3'.i CHECK
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR'
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Bet Backs
Forms B,Footings
Slab. Grade
Steel... 1
`'Roof.Deck
O.K.to Wrap
Framing
Insulation'
Fireplace�P.L.
Fireplace�T.O.
Party Wall Insulation
_Party Wall.Firewall
Exterior Lath'
Drywall -•Int. Lath
Final
BLOCKWALL APPROVALS
Final
PLUMBING APPROVALS
Waste, Lines
7WaterPiping
(t
-Plumbing Top Out
Shower Pans
Sewer lateral
Sewer Connection
Gas Piping
:Gas Test
Nal C4.
'
Appliances
!ry
�r
'= Final
;Utility Notice (Gas)
ELECTRICAL APPROVALS
`'Temp.. Power Pole
Underground Conduit
Rough, Wiring .
Low. Voltage Wiring
Fixtures
,: Exterior Receptacles
.G'Fj _
-Smoke Detectors
'.Temp:`Use of Power
. Final : .
il_dy_Notice (Perm)
OPERATION DATE :: ''' INSPECTOR:.
,MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air _
Combustion Air
Exhaust Fans-
F.A.U. - -
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
POOLS • .'SPAS :.
Steel
Electric Bond
Main Drain
Approval to Cover.
Equipment Location,
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment' Enclosure
O.K for -Finish Plaster
Pool Cover
Encapsulation
Final
COMMENTS.:'