0104-081 (RER)LICENSED CONTRACTOR,DECLARATION.
l h
5rebv, sffirm under penalty of perjury that I'am •licensed under provisions`of
H Chapter 9 •(commencing with Section 7000) of Division 3 of -the Business and`,
c4 � Professionals Code,, and my License is in full force and effect.
C P M License # l Lic. Class .Exp. Date
�.58481
Date Signature of Contractor
OWNER -BUILDER DECLARATION
9/30/02
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
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.
.311ATFI.0481 FUND 444908502
(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 riot 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: ADDlicant
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.
Signature (Owner/Agent) Date
PERMIT"
PERMIT
,BUILDING _
DATE.:. VALUATIONLOT(I TRACT
� FDf1fa tlD
JOB SITE
APN
ADDRESS
5.1-410 AVEM DA 015T&GON
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
R&R-BRO, WC.
52,41 p AVEN DA (fflACYjN
2,750 MG1Q)J,)?",K-WA
LA Q11T11- TA C.A.
MINAL HILL CAS . 90806
(562)5213-8000 CM0 3195
USE OF PERMIT
1`,r#l1.W., EE01<10 '
L
VALUATiON M;
Erpr I'M C'09T 03F' C;�11Eir�s°g:�a�i3�°:�Z�d I
`s`,;?3f t%w
,�y�' `�, y� p
P'L�.��ieffr Ai�j UUM14A .iY
KIM 01HEM iul 101-000-439-318 $4618D
CC1NS7'Z2.EXt,"i'eC3N if+EL 101 -OW -•418-000 1072,06
D ALUB- �:. 7 WCTJ..0.N cru MAN IMMIX
LF13's 1���1"431hmFIRM
$118.80
x$0,00
, ADM? rYOKS DICT NOW
APR 1 6 2001 _
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT DATE
BY
DATE FINALED
INSPECTOR
in
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings r�//7/� / 5
Underground Ducts i
Ducts
Slab Grade
Return Air [
Steel
Combustion Air i
Roof Deck
Exhaust Fans {
0. K. to Wrap.
F.A.U. i
Framing
Compressor
Insulation
Vents 1
Fireplace P.L.
Grills f
Fireplace T.O.
Fans & Controls f
Party Wall Insulation
Condensate Lines I
Pa _ .Wall Firewall
{
Exteflor Lath
{
Drywall - Int. Lath
- I
•
4
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond I
Footings
Main Drain 1
Bond Beam
Approval to Cover [
Equipment Location {
Underground Electric
Underground Plbg. Test 1
Final
Gas Piping I
PLUMBING APPROVALS
Gas Test i
Electric Final t
Waste Lines
Heater Final [
Water Piping
Plumbing Final {
Plumbing Top Out
Equipment Enclosure E
Shower Pans
O.K. for Finish Plaster {
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
I
Gas Test
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)