0108-350 (BLDG)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.
License # Lic. Class Exp. Date
r
Date '','� `:f ! Signature of ,Coltractdr�
�
OWNER -BUILDER DECLARATION
Thereby 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:
( ) 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.
S,) 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:
Carrier Policy No:
1m31162171.0a
(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
Code, I shall forthwith comply with those,provisions. �
Date I+, +� r Applicant "/' j % r : / r i it Y .t
Wdrning: Failure to secure Workers' Compensation coverage,is unlawfulAIA6'
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.
r
Signature (Owne'r/A� htj r; '(j f i b, • . Date
BUILDING PERMIT PERMIT#
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/)
DATE / VALUATION LOT 0108-350 TRACT
JOB SITE ^ ^
ADDRESS /D
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
POA iF E S"rRWKU))a �i 17AL AMOCSa ZION
DEL "1vS.M .PAC'JRC ENUL AL (%'1k '3',i AC-'0*R
F0 BOX. 1060
462 `rs"'3 EVENZY !AVE,43+ 2
ISA t4 jwm CA 92253
S01 -MA BE CH Cly, 92015
:5823
I..sJt'AL OFFICh INFORMATION
USE OF PERMIT
N.93C'P,y..9. NEOUS
75.160 ST. C13A,RIAM PL
i IC Vt:`'I.iiN`1',ARY SY'RUCTt RALo MODIFICATIONS
V,U:.1J,ATIt.W %S>pom La
nmxi'. m (,05'I OF CI.'9nmilanow
RE. RMEC M WhWARY
COi? E I'II.uc.7joyl WILE.._.. 101-000-418-000
STWHO MOTM FER, .'ASSP 101-000-31A I-000
SEP 10 2001
CITY OF LA QUINTA
FINANCE DEPT.
"-TOTAL" C(3R 'f IXTIC?N AMSAY �Sl`a CITWX
Ii30 PRE -MD
$�1,00
pOTAX., Ps:e%SY x0 IME 140W
dJ ✓.1 7
RECEIPT
DATE
BY
DATE FIN ED
I PE OR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
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
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
[
Drywall - Int. Lath
[
[
• _
�.
Fina} �_ _ _ _
BLOCKWALL APPROVALS
Final
i
[
POOLS - SPAS
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 Lines
Heater Final
!
Water Piping
Plumbing Final
{
F Plumbing Top Out
Equipment Enclosure
[
Shower Pans
O.K. for Finish Plaster.
[
Sewer Lateral
Pool Cover
[
Sewer Connection
Encapsulation
Gas Piping
[
Gas Test
}
Appliances
[
Final .
[
COMMENTS:
!T! // -011-01 4�pr
w1do
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Love Voltage Wiring
Fixtures
Main Service
I Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
DAVE. STEAVENSInspection Services.
Page of
.PROJECT #'. g) oa ;z
1% CLIE-N-1m, A
DATE.- Cj:
ARCHITECT
AP
CONTRACTOR% E C, MAR S A CjJ:
INSPECTION. REPORT'
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"dLe
CERTIFICATION OF COMPLIANCE'T6 the best of 6ur.. kn6wiedge, All of A I he; t , poortedwork,unless . otherwise noted,
substantially compli6s'With 6ppir6Ved;'0lans;.pp
edifiqatiohsand applicable sections of the buildih,g codes: This report covers
the locations of the work --inspected O'n-ily, and d "do - e' s not c 0 n s t itu t 'a -,engineering opIni6n, or D r6 i e ct c o nt ro 1.
4,
CERTAO.TOR NAME..
:INSPECTOR
DATE INSPECTOR SIGNA
S id t.
► t
CERTIFICATION OF COMPLIANCE Tothe best of our knowledge, all of the reported Work, unless otherwise noted,
substantially: complies with approved plans, specifications andapplicable sections of the building codes. This report covers
the locations of the work inspected only and does not constdute engineering opinion or project control.
CERT.-NO:g��3 �A 5V 'INSPECTOR:NAME
int
DATE A��1 L a?t�0 2= INSPECTORSIGNATURE� 4rl
DAVE STEAVENS
Page. j_ of 2 �
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CERTIFICATION OF COMPLIANCE ToIthe best of, our knowle'dge,`all of the reported work, unless otherwise noted,
—,"substantially. complies with approved plans, specifications and.applicable sections of.the building:codes. This report covers
the locations of the work inspected only and does notconstltute engineering.`opinion or project'control.
CERT. NO.09�.3 T U INSPECTOR NAME
DATE /'r &P op J V Z ~INSPECTOR SIGNATUR�A-
u�