0103-101 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under perialty of perjury that I am licensed underprovisions 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
29
pate - '� Signature of Contractor ZA
/+
OWNER -BUILDER DEC RATION
I hereby affirm under penalty of perjury that I m 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.
EX XV PT
(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
sybject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with I 4psre provisions.
Date: ^'" • Applicant a�
Warning: Failure to secure Wor ers' Compensation coverage is unlawful and
shall subject an employer to cri final 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 spection purposes.
Signature (Owner/Agent) Date "' ~feyIf
Y•'v. Ly
BUILDING PERMIT PERMIT# _ • . `''
DATE VALUATION LOT ��, TRACT ,
BUK 162' .
JOB SITE
ADDRESS
cS2-61,,0 AVM -DA OR`0C)fd'
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER
RANDY & sltkRom MIS
RUDY'S MASONRY ,
7S-5415 OA.GUAR0 ,IAOAD
it 547 WIRIM O PALMS
LA QT:Eitr� A CA 92233
CKI[IMDRA1L CTTY CA 92234
(760)409-8582 , CBVt 634.6
'b
USE OF PERMIT
86 IA 5' Q". 1)EN IVAI L.014 IX1S7'T1d0 RZT.ANINO WALT
611, WAI J, it .43a 1ff
FFv'IIWTKD C(?'o 1' S'SF CONSTRUC1101Y
AW.00
.
RUN IARC'
CON'V;RUCT9t"JN rU? 101-000-418-000 S3tI.Q£�
a
LnS :CSE -PAM FUS
$0.00
APR 6 200T IBM" IT&S DUE NOW
CI FINANCE DEIP1 A
9:9.40
RECEIPT
DAT
A/,
BY
DATE FINALED
INSPECTOR
Kin
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts {
Forms & Footings
Ducts t
Slab Grade
Return Air [
Steel
Combustion Air }
Roof Deck
Exhaust Fans J
O.K. to Wrap
F.A.U. }
Framing
Compressor }
Insulation
Vents f
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls {
Party Wall Insulation
Condensate Lines J
Party Wall Firewall
{
Exterior Lath
f
Drywall - Int. Lath
J
J
J
Final J
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel J
Set Backs /
Footings �� % 5 /
Electric Bond [
Main Drain [
Bond Beam [�L� /6_� rj �/'
Approval to Cover I
I
Equipment Location {
Underground Electric I
Underground Pibg. Test J
Final
Gas Piping J
PLUMBING' APPROVALS
Gas Test I
Electric Final J
Waste Lines
Heater Final
Water Piping
Plumbing Final J
Plumbing Top Out
Equipment Enclosure E
Shower Pans
O.K. for Finish Plaster }
Sewer Lateral
Pool Cover }
Sewer Connection
Encapsulation }
Gas Piping
}
Gas Test
Appliances
J
Final [
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)