0104-219 (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
73315 D O r�31��2F
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).
( ) 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.
(;') I have and will maintain workers' compensation insurance, as required by
Sec ion 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.
CAL IT 1;(DIK"MNI Y NW21^A,A
(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: Applicant
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.
BUILDING PERMIT PERMIT /
DATE VALUATION LOT 0104.219 TRACT
JOB SITE APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
PGA'W&, Tf fiEGMENT'L€iiL A► SOC€A:[TON
ISO BOX 1061)
LA Q1:7)NTA CA 92253
USE OF
:I&SC F;LI."FI01'7S
DW_ MAR. P,AC`T.FA: GENFX' AL —'ONTPJ
130LANA:UDs:A(M Cts 92075
(�SSOP92.15()0 l DI)i 5823
bOCAL OFIFICE MF0RKfiYVON
75-160 ST. CHMLES PL
IW -446, M-43% & 541422 OAK 'f'bCW E - SUIL.I3rNU TYPE
O OiAIN TARP STRUC.TUI3AY, MODIFICATIONS I Jl
VALU.A`NON
4000,09 Ix
hs}°7.' IXrED £x081 OF CCa3tM911RUCMON
00Wsf9'RUC110N ME 10 1 - DDO-4 18-000 5207,00
STRO140 MOTION FrZE - Fi'a✓5;f D 101-000--241-000 03.im
AA W n LMS PRE-PAM.14
APR 2 0 2001
CITY OF LA OUINTA
RECEIPT E
CAI, h`EIMff PTES DUE POW
BY I DATE FINALED
INSPECTOR
2010680IM
$209.00
$000
$20.9.00,
Signature (Owner/Agent) Date I I I I I I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE IINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts i
Forms & Footings
Ducts i
Slab Grade
Return Air {
Steel
Combustion Air
Roof Deck
O.K. to Wrap
_
6�1
Exhaust Fans 1
F.A.U. t !
Framing
/8
Compressor F
Insulation
r
Vents I
Fireplace P.L.
Grills I
Fireplace T.O.
Fans & Controls l
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lat
Final
�1�/—
Final
YF
POOLS -SPAS
BLOCKWALL APPROVA
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
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: I
I
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
I
Temp. Power Pole
i
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
4
Smoke Detectors
Temp. Use of Power
I
Final
i .
Utility Notice (Perm)
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OF PLIANCE.'To the best,of. our knowledge, all -'.q,,r,6.p6ft6'd-work ',,--"U"nless otherwis'e'noted,
'�VbstantiAlly complies -H approved"""I " ' ' - * ' " , t
wit ' - fficliii6n�--- nd,"' pplid6bI6 sections '6f,thid" b'Uil
"p �qs;-speq ding. codes. This report covers
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,4he locations of the - work inspe, ted of 6 i4464nbin6firing &i61on"' t
y -,qr. prpjqc control.,
CERT NO.7-:`j
0 INSPECTORNAME %.Yr- 0
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Page Z of
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Inspection: Services - {
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BLDG. PERMIT #:
ENGINEERI),- i, ,JL
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DATE
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INSPECTION REPORT
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CERTIFICATION OF'COmP I' To the best.of our knowledge,, al[of the.reported work; unless otherwise noted,
bstantially complies with;approved plans,`spec ficaUons and applicable sections'of the building.codes. This report covers
locations of the.work inspected only, and`does not constitute engirieenng.opinion or project`control.
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INSPECTOR NAMVlt.
INSPECTOR SIGNATU
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Insp,a on vrvices .�
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INSPECTION RETORT'I
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CERTIFICATION OF COMPLIANCE To -the best of burknowledge, all of the reporteii work;: unless otherwise noted, 1
substantially complies with 'approved plans, specifications and -applicable sections'6i4he building, codes. This report covers
the locations of the work inspected only aril does: not constitute engineepri inion or project control.
CERT.NO. �g��,3 �g SV INSPECTORNAME- �J �, J,tEA1I.r—►JS
DATE / T(� J6 ai:I" x :T.
INSPECTOR 81GN
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