0010-110 (MISC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
f— Che.pter 9_,(f.1ommencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACT
04 W Professionals Code,and my License is in full force and effect. i , ��1)JFd��t�'tD
5 ch License# Lic.Class Exp.Date l " ' 3 4C)0O
JOB SITE APN
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Z Date l�� e�:'��'�rY) Signature of Contractp . • f�' OWNER CONTRACTOR/DESIGNER/EN (NEER
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J U OWNER-BUILDER DECLARATION W".CA23�f'F.:�9UMSH,INC. VJTWV&SrWiNw,Lmio.
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 14Z,5 E ��NNa�;�DI tV 1425 A.�.SNNER;ITY D Z,
~ a License Law for the following reason: r AZ a.50.44 .�
Z_ ( ) I, as owner of the property, or my employees with wages as their sole .
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compensation,will do the work, and the structure is not intended or offered for �� d ?. "Ia+ Ee MIX, 4990
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project Sec. 7044, Business & Professionals 109M '
Code).
co () I am exempt under Section B&P.C. for this reason to . c�a fF OP i'. fSC,`.`I3.O.Tt TRAILER.pt:6#' fw MtYP 2> 0�234
N Date Signature of Owner
ON
d Q WORKER'S COMPENSATION DECLARATION
> z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O O 1 have and will maintain a certificate of consent to self-insure for workers' '6r UtATION 40100 LS
X W compensation, as provided for by Section 3700 of the Labor Code, for the
m _Q performance of the work for which this permit is issued.
Q I have and will maintain workers'compensation insurance,as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
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tl rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
cb O INI COAIPAN Y OF x WDE17004 1 W F811MAM COS'0F. C`. N91"AMMO 4M00
Q (This section need not be completed if the permit valuation is for$100.00 or less). "':*;i? FM Y
J ( ) I certify that in the performance of the work for which this permit is issued, 'SEM?CONS'I'RU, C:TION TR I.I.M 101 0.00.42.3.000 $200114
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 provisions-of-Section 37Qa,.Gf•the Labor
Code, I shall forthwith comply with those,-P-rovlslons.
//Date: /,jos•2,.j Applicant ""
4f 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. a
IMPORTANT Application is hereby made to the Director of Building and Safe
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 �;(� ^qp;j; is �g 'jt")) f�, i'j� P�t`i E'jt �Z $200.00
any permit issued as a result of this applicaton agrees to, &shall, indemnity UMS MI&PAM FEES $0.00
.& hold harmless the City of La Quinta, its officers, agents and employees. q
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 0 L•I;'ORAM. 'FUS DIM NOW, �
permit, or cessation of work for 180 days will subject permit to cancellation. LK
I certify that I have read this application and state that the above information is •• I IIIIIII VIII II II II IIII
• correct. I agree to comply with all City, and State laws relating to the building f 34p
construction, and hereby authorize representafl ev s of this City to enterupon IE Ji
the above-mentioned property for,inspection pp:5ea. } - - --
� Y RECEIPT ATE BY t DATE FINALED INSPECT
Signature (Owner/Agent) -�`"�� `� Date A%`�'+/✓� g; j�` j r� "'� ju"'
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
t. BUILDING APPROVALS MECHANICAL APPROVALS
,iet 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. I Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
'i 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 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
Sewer Connection Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utilq 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)