0301-407 (BLCK)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
R8N'ssl6nals Code, and my License is in full force and effect.
License # Lic. Class / Exp -Date
I.S.
/
Date . 11 Signature of Contrac-r
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( )
if as owner ofithe 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 IipetSsed
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,COMPENSAjT,ION DECLARATION
I hereby affirm under ,penalty of perjuryf one of the following decla� ons:
() I have and -Will maintain a certificate of consent to self -insure for kers'
compensation, .,is ptovided: for by Section )3700 of the Labor Code, f • r.tbe
performance of the•workr which this permit is issued.
�(%) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor'Cbde, for the performance of the work for which this
permit is issued. My woNers''compensation insurance carrier & policy no. are:
Cartier $':'ATE J 1a. Policy No, 229-W23566-2003
(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 sous to become subject to the
workers' compensation laws of California, and -agree that i!0hould become
subject toAhe workers' compensationaprowslons of Secti X3700 of the Labor
Code, I {all f rtf�with comply -v, itch It ose prove ions/l
Cafe:! Applicant e" .✓� ��.-i
Warning: F ilure to secure Wor ers' 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 Buildi%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 i"s 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, agent's '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 rep.es ntatiyes of this City to enter upon
the above-mentioned property for ins�tion purposes.
Signature (Owner/Agent), • �l't e �' %� _ "L —' Date����
Win. wr re., s....-
qj'' SBUILDIN'G PERMIT PERMIT
r)�-�
DATE VALUATION ,• LOT TRACw,
JOB $ITE.
ADDWS:. - 52- * A VRM 4.3.1}3. EG,(Xq
' r
APN
- ..
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WRIAM XAHN' 4
�3k�137 CiATD' ` ai.•Ci"NT
52.228 AV IC1A
ri±4223?
4 .30e- .- -cly.� m.Z.
LA t"1UINT�a � C�
t�.l��"4:� 1+�F��:i�v CA 4221':)
.
�a6Ci;Y7i3.40
USE OF PERMIT
CCSM';IlIATIfiJN
114 1.F: 6123 ; 1�Gf?A#05; tlJ�PTRMAJ,, FOR 4
L101TFWTJRES, P/N 3CAP
t.; R 1.b:1PMR......
d 1ft, WALJ, 114.(10 1,V
LNTINAM cosr 31+' Ci4ST1,110.9
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i ii.J.4.LpJ'.b•.l' &' ,i:..1"a
CONSTR:10TION 1 ' )01-000-418x000 3,G
EL,E✓ . NUI C.A L FEE '. 101 �GC)Ct4'2<1-•WO ! 'M.60
D- e' •
J.AN ' 3 0 1003`
CITY
OF LA QUINTA
FINANCE DEPT..
gn-1'ti)'J'm, C01d�iRucTIc3 �' X533 3PI: AR (.',TTR0K
• F.;i?►J� I'r��'•:13.PtiC1'-3 �:
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TOTAL PKRI-11T VOM7N;6ENOW
01*1 .00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 i
Fireplace T.O.
Fans & Controls I
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
f
(
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs FY
Electric Bond [
Footings
Main Drain
Bond Beam
Approval to Cover {
Equipment Location
Underground Electric I
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 1
Sewer Connection
Encapsulation
Gas Piping
Gas Test
I
Appliances
_
Final
I
COMMENTS:
Final
Utility Notice (Gas)
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 (Perm)