0309-069 (BLCK) s
LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMITk
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and (Y_"�(36.3
DATE VALUATION LOT TRACT
W Professionals Code,and my License is in full force and effect. 09AW20C S400M '3y ONLA a
O ch License# Lic.Class Exp.Date
LO JOB SITE APN
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W `� 9307� ]� ` 07i�T1/2C ADDRESS W•900A�'E.NUZ 47
1,7� Z Date Signature ofContractor /� OWNER CONTRACTOR/DESIGNER/EN INEER
O � , J
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J U (0 OWNER-BUILDER DECLARATION VISTI�LAQUIIr M,ZLC ORI' DIRI.3'.i S
W W I hereby affirm under penalty of perjury that Y.am exempt from the Contractor's 45-524*Mi�F STREET 3M01 113,)CrER.ST MTF,300
~ U) License Law for the following reason: DNDIO CA. 32201 IMAM DESERT C.A. 32201.
Z_ ( ) I, as owner of the property, or my employees with wages as their sole �F6�3 Q•r5�32 �, 1395
compensation,will do the work, and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed GMWERALDUMDING
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 16 E A'6'WAIL L PER CITE`STANl'1ARTIFOR TRASH ENCLOSUR:,PE?R.CDL)
<'`) () I am exempt under Section , B&P.C.for this reason Ak'AROVS PENiF 2001 IBC
N Date Signature of Owner
ON
rn
d Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' 6 t' 'WALL 16.00 1'F
X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q () ( ) I have and will maintain workers'compensation insurance,as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
LZ permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier IST.P'iJNO Policy No.
� 12429'24-W EST Wrll)C OST OF FL°Clrw-RI CTIC)N 400.00
00
a PERM.'7LZ'�'I`,ATAWARY
J (This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCTION FU 101-000-41$•000 $13,06
( ) 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,,an'd agree4hat if I should become
3 subject to the workers'compensation provisions of/Se tion 3700 of the Labor
Code, I shat rfo with comply with th se prG isig�.
✓Date: �� / �' Applicant—
Warning:
r -
Warning Fa ure to secure Worke s' Compensation coverage is unlawful and
shall subject an employer to criminalpenalties and civil fines up to$100;000,in
addition to the cost of compensation amages as provided for in Section 3706
of the Labor Code,interest and attorney's fees.
IMPORTANT Application is hereby made tc 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 SUB-TOTX,CONSTTtUMIOX AM P.T�.A+b'C, ICK .
whose request and for whose benefit work is performed under or pursuant to IFBS PRE-PAM W03 ,�� 00
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. A
2.Any permit issued as a result of this application becomes null and void if ) vU `I' rAx,rEyndT£FP'6+ i;s Dlw Now $35.00
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. -
- 1
pp SSP 0 8 2003 �� � ���1�������������I���
I certify that I have read this application and state that the above information is 06
• 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 CITY OF La CsUINTA IE
� FINANCE ry�PT.
the above-mentioned property for inspe tion purposes.
RECEIPT DATES BYt/ DATE NAL INSPE R
��Signature (Owner/Agent) % 11 I2 Date D
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE TINSPECTOR
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
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Ptbg.Test
Final p Gas Piping
PLUMBING APPROVAL/S
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
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL' APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)