0211-177 (PLBG) LICENSED CONTRACTOR DECLARATIONPERMIT#
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I hereby affirm under penalty of perjury that I am licensed under provisions of BOt-DING PERMIT
F— Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOTTRACT
N W Professionals Code,and my License is in full force and effect.
O =) M License# Lic.Class Exp.Date
JOB SITE APN
ti LU �'� 134381 BMCryt�i/.'if��r ADDRESS ;�Ei�➢`i2 c� �1 _ -
r.- ��" L� "'U ✓4/�Ij/�'�"*" OWNER CONTRACTOR/DESIGNER/ENGINEER
o Z r`� Date Signature of Contractor-
(0 O.6
I` H OWNER-BUILDER DECLARATION RICHARD BAKER MATU40T,RAD WM4&Xt�1;.3fl"!KMRSATA
J U '� 955 C�:AT�.f�.�.LO T?_XTP�r"C3If x.100 ;e902��;j�:RRAIT A W,
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a- License Law for the following reason: 14> ANGELES CA 90048 SANTA MONICA CA 904W
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (31(J)2611-181 6 0113]X
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 IIIIIIIIIIIIIIIIIIIIIIIII
contractors to construct the project (Sec. 7044, Business & Professionals �'t ! 54
s
Code). RLLLOCATP,' PA0P :N9 TA J4K IE
L O I am exempt under Section , B&P.C.for this reason
N Date Signature of Owner
ON
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Q WORKER'S COMPENSATION DECLARATION
p 2Z I hereby affirm under penalty of perjury one of the following declarations:
LO H IM
O O 1 have and will maintain a certificate of consent to self-insure for workers' VF,l.L1A4>N 1,600,60 1,:i
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 C) '(;�) 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
2 LIDH permit is issued. My workers' compensation insurance carrier & policy no. are:
Polis No.
Carrier 00 STATE FUND y 1514151-02SIT`1LkAZ`lZ CONTO '{t3NS7tkc3]tpE3k?.tV
C7 , TIER .°"E OUMMARY
J (This section need not be completed if the permit valuation is for$100.00 or less). PZ XM0IW0�7_vl' 101-000-119-000 j d�
( ) 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 rz
workers' compensation laws of California, and agree that if I should become ;
3 subject to the workers'compensation provisions-;6f Section 3700 of the Labor
Code;I shall forthwith comply with those-pr'o�lisrorr9!V/
'Date: C1 'Applicant••�='` B` r
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 pp';
addition to the cost of compensation,damages as provided for in Section 3706 NOV
of the Labor Code,interest and attorney's fees. _.
IMPORTANT Application is hereby made to the Director of Building and Safety CIN OF LA gUiriT':a
for a permit subject to the conditions and restrictions set forth on his r FINANCE DEPT.
application. x '
1. Each person upon whose behalf this application,is made&each person at N„ o
whose request and for whose benefit work is performed under or pursuant to l'`Ji"� iTYC'7ZC}I�.HLA 1a� � `t 1� 1 i3'(JQ
any permit issued-as a result of this applicaton agrees to, &shall, indemnify ;3N ; `7?a��•13T.' Ef+i $0,00
& 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 Yl"Gr�: ' : !�!I" S d7Ctt�NOW
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 ins�sjjpection purposes. RECEIPT DATE BY D INA i SPECT
"Signature (Owner/Ager~t)' �'��� � Date's �y���� �� '� 3/+j
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
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 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 _
Utility Notice(Gas) v
ELECTRIC L APPROVA�.� ,
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Smoke Detectors
Temp.Use of Power r
Final
Utility Notice(Perm)
hoV-22-2!'02 09:48 t IARMUL. KHL141 NtK M':)Z=d_l1 -- --
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TrYLE: PROPOSED PROPANE TANK MARMOL RADZINER+ASSOCIATES �����'
SCALE: 1/20"=1'-0" DATE: 11/21/02 2902 NEBRASKA AVE_SANTA MONICA,CA 90404
:PRUJFCT#: 2170 PROJECT: BAKER TEL 310-264.1814 FAX 310-264-1817
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