0001-075 (SOTB)LICENSED CONTRACTOR DECLARATION
I hereby a * ffirm 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
'70866 B ,
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt I rorn the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, 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 f or workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(4�A`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.
ZURICH INSURANCE WC633396547
(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
a a
workers' compensation laws of ? CaLfiforn I . nd agree that if_l should become
subject to the workers"' compensati p rovIsIps of rSo 3 00. of the Labor
ose ns
,Code I sh 11 fo comply with os
hkAnnfirnnt
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 Stqk(e laws relating to the building
construction, and he 17y_`a�thorize re resen ati es of this City to enter upon
re
the above-mentioned pr y f rlrn* e t p r e
no i K
Signature (Owner/Age t Date
PERMIT#
BUILDING PERMIT
DATE VALUATION LOT TRACT
1.W0!V2(K 4"31.20
JOB SITE APN
ADDRESS
49-451AWNWA Or-MEGOIq
OWNER CONTRACTOR DESIGNER ENGINEER,
MR, DRUXPT RUFSORII, IWC Kffi, uown cmpo"1,1014 I
49,499 MENHOWER DR 55-92OPGAMN-D
LA Qjwn. CA 92253 LA QMWA CA 92251
- (760) C!Bl,#. 5323
,5,64-7-166
USE OF PERMIT
ONEWERAL ]YOUDD413
MM -TOTAL COMRUCMION AND PLAN CITEOC $107.98
12215, P.R.&PAROM3.9 � X or)
'TOTAL -pr%Rmr FKES DUE NOW
RECEIPT DATE BY E FINALED
C)
DAT
0ARAWCAIRPORT
22.00 91?
FUIT11MA71D COST OF COMMUMION
431.20
ftldffr rp IINSUIAMARV
PLM CHECK FRE
101-000-439-318
$91,73
CONSTRUCTION M
101 -00" 18-000
$15.00
LeLECTRX-AL M
101-000-420--000
SIS.00
,PLUMBINGFE8
101-000419-000
S21.09
ORADNO Fr1,R
101-600-47.1-000
220.00
STRONTO MOTIOM FEE - CM1244
100-000-241-000
$.50
ART M PUBLIC PLKOE8 .. COW 701 -000-235-000
$2.16
T.)PV-TiJX)PER 1,01R&CT FEF,
X 57
MM -TOTAL COMRUCMION AND PLAN CITEOC $107.98
12215, P.R.&PAROM3.9 � X or)
'TOTAL -pr%Rmr FKES DUE NOW
RECEIPT DATE BY E FINALED
C)
DAT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings 'U_� 2 _
Ducts
Slab Grade i
Return Air
Steel i
Combustion Air
Roof Deck I
Exhaust Fans
O.K. to Wrap r
F.A.U.
Framing ]
Compressor
Insulation (
Vents
Fireplace P.L.
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I
Exterior Lath I
Drywall - Int. Lath J
I
Final
Final
—
BLOCKWALL APPROVALS'.'
POOLS - SPAS
steel
Set Backs ]
Electric Bond
Footings ;
Main Drain
Bond Beam ?
Approval to Cover
I
Equipment Location
Underground Electric
i
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
I
Gas Test
Electric Final
Waste Lines ]
Heater Final
Water Piping j
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping ]
Gas Test )
Appliances ]
I
Final
I
r
Final I
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures }
Main Service I '
Sub Panels
Exterior Receptacles
G.F1
Smoke Detectors 1
Temp. Use of Power
1
Final ]
Utility Notice (Perm)
COMMENTS:
"