0109-159 (RR)LICENSED CONTRACTOR DECLARATION
U)
I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Rco W Professionals Code, and my License is in full force and effect.
= ch License # Lic. Class Exp. Date
770910 0,1.39 1If
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I I )`.' ()/Zt.
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).
V) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt u der Section B&P.C. for this reason_
Date Signature of Owner k
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
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.
11TA3 :F i?:N.f? :ls"S-tl0•rtt?U I ��+)`Y
(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: � r _ Applicant i
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, indemnity
& 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.
Signature (Owner/Agent) % Date E r
BUILDING PERMIT PERMITpJL
DATE VALUATION LOT TRACT
(A)!EW70f.
JOB SITE APN
ADDRESS
OWNER
Rtl), BOX 1060
'LA. QTANTA
USE OF PERMIT
R&ROO..F WITH CLASS' A kitATLYf.f.AM. OLD0 30:
.A-75 a4-7!x6,41-'YM,':q--n I
V A.I.fJAT1014
l:uffl .'.fit. ROOTdCma,
F3-597 YF.Aal n.
INDR".) a 922A
C?66)347.9869 M1rII
I
CITY PF LA QUINTA
1;°0L.00 LS I. FINANCE DEPT.•r
ES'i.lA7.l J79D COST OF COIF SYRUC.iiON
f`.9;)iM:i'i'.!'.I1`:k' 913:iNtiIi/lARY
FLIfROOale FEE 101.000.4 ! 6_000 $30,00
fC)I3 'I'f?"1 p4i.. COtJM.1-TC7(014 MID PLAN CHECK
JYM TYRE -PAID x.01
$30,00
$0.00
b
�O.tifl
F
RECEIPT I DATE ' , ! I BY I DATE FINALED I INSPECTOR I I
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framina
Fireplace P.t_
Nfrt;-'armT.O
Party Wall Insulation '
Party Wall Fire,uali
Exterior Lath
�11� 'Lath
7
Fii*-
rJ �ij l.d U�
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts j—
Return Air
Combustion Air
Exhaust Fans
F.R.U.
i ompressor I
Vents r
Grills ' I
I Fans & Controls I I
I Condensate Lines I I~
A v ,/
{f - — POOLS - SPAS �
Seel I_ —
Electric, Bond I I
Main Drain.
I
Apprava; to
--
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice
_
Underground Electric
Undergeound Pibg. Test
rbnal -
I—
7 Gas Piping
>..u:�i%�xr
GnTest
-
Electric Final
Lines -
k
- Heater Final
J~ I
— ` —I
Plumbing Final
- - — - �-
Plunbing Top OurI
,I
—
]_ Equipment Enclosure
t
Shower Pans
-
I —
-
i O K. for Finish Plaster i -
-
Sewer Lateral
, - -
1 Pool Cover
Sewer cvrrnecli_•11
- E
— — _—�
Encapsulation -
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice