0311-156 (BLCK) LICENSED CONTRACTOR DECLARATION - PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of - BUILDING PERMIT.
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and " 03114%
DATE VALUATION LOT TRACT
W Professionals.Code,and my License is in full force and effect. 11/17/200 $3,791.00
O M License# Lic.Class Exp.Date
r Q LO JOB SITE APN
r W 663077 �j II�L ADDRESS `/8^900A.VXNUF,477
Z I-- Date �� r)� Signature of Contractor ���f/�' f� OWNER CONTRACTOR/DESIGNER/EN (NEER
co 0 � r 4fl
r ~ coo OWNER-BUILDER DECLARATION VETVA ORR.BUILDIMS
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 45-524 T WNIsAVR 39.301 R'DG 1 ST h 1. 300
~ U) License Law for the following reason: DMIC) Ws 92)20 t PJ'AI 14 DESMT CA 92201
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)360-06:12 C"I3IN 1.395
• 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, a(exclusively contracting with licensed C MAKRAL 1MX) W
IIIIIIIIIIIIIIIIIIIIIIIII 05
contractors to construct the project Sec. 7044, Business & Professionals
Code). 1501...'!t'.x 6"HION OA11:DW`4iy.AU.CITY ST.A.NI)ARD IE
cYIllO I am exempt under Section B&P.C.for this reason PER APPROVED COMM,
N Date Signature of Owner
ON
0)
CL Q WORKER'S COMPENSATION DECLARATION
p 2zI hereby affirm under penalty of perjury one of the following declarations:
LO O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' 6 FT'WALL
X W compensation, as provided for by Section 3700 of the Labor Code, for the
mQ performance of the work for which this permit is issued.
Q U ( I have and will maintain workers'compensation insurance,as required by
O 0 Q Seg on 3700 of the Labor Code, for the performance of the work for which this
Il 0) F< permit is issued. My workers' compensation insurance carrier & policy no. are:
cb z Carrier9TA TE PITOI) Policy No. 12421Q4-02 )KSrI1dA'=C.10ST oyr-C01gF;Rt (.M01q
C) d'RRAdi r FTE E GARY
J (This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCTION FEE 101_00014- 11 y 8,.000 $6310
( ) 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
subject to the workers' compensation proovisll s of Section 3700 of the Labor
Code, I shall forthwith comply with hoser•Cisio s.
Date: 0 ' Applicant ���
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 &M.TOi�f°C)WkT?'CJC``flC_*T ANDPLAN•Csl'�C $63.00
whose request and for whose benefit work is performed under or pursuant to �0
any permit issued as a result of this applicaton agrees to, &shall, indemnity LF�� PRF,-;PAM
PFSS 00
& hold harmless the City of La Quinta, its officers, agents and employe ----
2.Any permit issued as a result of this application becomes null and voi I�f '7[VYAL,FirRA ,1'I','ar,D*VE NOW $10.00
work is not commenced within 180 days from date of issuance of s
permit, or cessation of work for 180 days will subject permit to cancellati NOV 18 1003
I certify that I have read this application and state that the above informatio is
• correct. I agree to comply with all City, and State laws relating to the build ng
construction, and hereby authorize represent fives of this City to enter u on .CITY OF k r: C3t,i;Tt's"A.
the above-mentioned property for inspedtion •urposes.
-DATE--J BY DATE F NALLD INSPECTOR
Signature (Owner/Agent) /.' ^� 's `- Date if s/
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms✓3 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 8 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 Plbg.Test
Final p Gas Piping
PLUMBING APPROVA 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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)