0306-108 (COMM) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT/f
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 and
DATE ,� VALUATION LOT TRACT
W Professionals Code,and my License is in full force and effect. doc 34 3(0 23
0 ch License# Lic.Class Exp.Date
^ JOB SITE APN
LLI Y64�934 � � � � fJ 13117,1 ADDRESS sB,. is Ott��1lEI�11t:I+.,62
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,Z r— Date Z 4,Signature of Contractor -� 1 OWNER CONTRACTOR/DESIGNER/EN (NEER
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OWNER-BUILDER DECLARATION �7i C.�:HU3M1 c'F�LH.TiOWES
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W W r1_ I hereby affirm under penalty of perjury that I am exempt from the Contractor's 61'26.1)AVENUR 62 61-26x4 A•�W..�IW-62
H rL License Law for the following reason: LA UTNTA CA,, 92A�!TT
883 1 11OsA elk 92883
Z_ ( ) 1, as owner of the property, or my employees with wages as their sole f,9093$•8996 CBLbslki
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE of PERMIT
( ) 1, as owner of the property, am exclusively contracting with licensed /J2GwLA�
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 143 SQ.Fi'.COMPORT STATION 02. °S`OCC. TYt+'X VW
c`) () I am exempt under Section , B&P.C.for this reason
CONSTRUCTIONN Date Signature of Owner
ON
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2 < WORKER'S COMPENSATION DECLARATION
C, 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Ln Q � PORC:HIP ATIO 100.00 SF
F- p ( ) 1 have and will maintain a certificate of consent to self-insure for workers'
X W L—L compensation, as provided for by Section 3700 of the Labor Code, for the CIA RAOWC.ARPOR.T 14:;.AO SZ
O Q .,performance of the work for which this permit is issued.
Ib Q U ( ) I have and will maintain workers'compensation insurance,as required by
OLIDQ Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
`t Z Carrier Polic No.
w t�AT:ICaI;i{�L 0141011 1? y r0.�33t1S+ l+'�1 �'I'l��C 016''r 0:N'001"7C'Rltift';'a'IO-K 4,3.72.019
J (This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCTION FM 1.41,000-410.000
( ) I certify.that in the performance of the work for which this permit is issued, PIAN CHECK FEL 101-000-439••318 $90.3,7
1 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 MECUNHICAL FEE 101.000.421-000 $23,00
subject to the workers'compeCsation,provisionslof Section 3700 of the Labor ZL-ECTRIC.AL FEZ 101-000-4252-000 $31.40
!-'`Code,I.shall forthwith comply with ithose.p`o isioo`s� ('� PLUMBING FRE 101.000.419.000 M. t o
Date: ?'!Z J Applicant - ` .Y ,V-+' STRONG MQT1024 ice+ Comm 100-000-24 1-000 $.i0
Warning: Failure to secure Workers' Compensation coverage is unlawful and ODIC!r"FE, .101-000-423-000 $19.00
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. 11
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 SUB-ICZTI�.aC`'t�N.T1a 3t"�I°.I0W APLAN�llCK
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 � •I'A11JIT_' .TI $Lf°04
& hold harmless the City of La Quinta, its officers, agents and employees. kc,4TV"..
2.Any permit issued as a result of this application becomes null and voidif XFAL',�,)f�+'1Vj21'1110rS XA'J;�j1jQ'1j�7 ���N17,13work 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 2003 I certify that I have read this application and state that the above information is IIIIIIIIIIIIIIIIIIIIIIIII64
correct. I agree to comply with all City, and State laws relating to the building IEconstruction, and hereby authorize representatives of-this City to-enter upon AQUINTA _ - -
the•above-mentioned property for ins action pu posies. FINANCE DEpT
ty ..,
/ ,�\ RECEIPT DATE BY C / EFIL INSP R
/Signature (Owner/A ent f JID,ate cdd� ---...... + �'�� �` !
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 A fcb. 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
BLOCKWAL 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)
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)