0007-228 (BLDG) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business andDATE // VALUATION LOT 0M7"'�3l� TRACT
401
04 W Professionals Code,and my License is in full force and effect. Mlz�76
tn�" .a0 y( 25f 147-Z
O n M License# Lic.Class Exp.Date
JOB SITE APN
Lu �i�I• �flS C29 ,� / 0"IlU1�2 ADDRESS 81 440�,VI N T.E M -
Z r-- Date�'96 dp Signature of Contractor= -"'' i� OWNER CONTRACTOR/DESIGNER/EN (NEER
r- ~ CD I�.f
OWNER-BUILDER DECLARATION KSL DEM)OPUWr CO POMIOX SA$OR SC)MY
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 55.920 PC+ABLVDI 43 66 S.LC7I1:1MANA ATME.0
~ U) License Law for the following reason: LA QUNTA CA 92253 PALN1.1 U:WRT CA 92211
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)G74-0666 OBLO 6214 .
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 �iS�N1AIrj3T77C1C3
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 230 Lt''. 61H 0ARDEN WAL....GORCO STANDARD
CY)LO () I am exempt under Section , B&P.C.for this reason
N Date Signature of Owner
ON
O)
EL— Q WORKER'S COMPENSATION DECLARATION
p 1 hereby affirm under penalty of perjury one of the following declarations: *`
Lo Fa— O ( )1 have and will maintain a certificate of consent to self-insure for workers' �'��� 230.00 1.�
X w �: compensation, as provided for by Section 3700 of the Labor Code, for the
Om J Q performance of the work for which this permit is issued.
Q C) °(; I have and will maintain workers'compensation insurance,as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 1,EC3ION INSURA7,1C"1; Policy No.
Cb W031231I293 ES.'FJ1 ATED COST OI+CONS T7C7',[ON 5175DM
1- 0 PlnMWI'E "�&3@1AN lI
J (This section need not be completed if the permit valuation is for$100.00 or less). C:013€lT1tUC"T1cN FEE 101.000.41 -000 SQI.t3I?
( ) I certify that in the performance of the work for which this permit is issued, 1.
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 provisionsof,Section 3700 of the Labor
Code I shall:forthwith comply with t ose provisions. / N
Datej�'�4 ApPlican�; i�I% ,�f
PAI .
Warning: Failure to secure Workers'Compensation coverage is unlawful and JUL 2 6 j
shall subject an employer to criminal penalties and civil fines up to$100,000,in 2000
addition to the cost of compensation,damages as provided for in Section 3706 "ITY _
of the Labor Code,interest and attorney's fees. OF LA +�9��! Y/
IMPORTANT Application is hereby made to the Director of Building and Safety ft
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 1 81014,-TOTAL CO�NStxi MION AND PLAAT CI1I:Ck. t€1.OA
`
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 L=13 PRE-PAID T-:FSB $0,00
& 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 TOT-AL►PIMMTTYMISDUR
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 f IIIIIIIIIIIIIIII�IIIIIIII
' correct. I agree to comply with all City, and State laws relating to the building '• 74
construction, and hereby authorize representatives of this City to enter upon 4 _ } ` IE
the above-mentioned property for inspection,rurposes. 4�
BY �
Signature (Owner/Agent), RECEIPT DATE DATE FINALED INSPECTOR���� /� Date � /��-
I
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 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 i Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.Test
Final �� � "' Gas Piping
PLUMBING APP OVALS 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) i