BLDG (0110-107)54300 Avenida Madero
0110-107
T LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
l`_ ` Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) ch Licens. et # Lic. Clasq Exp. Datet1_ rl-
I LU
/ & = '
Z Date !' Signature of Contractor
O r
J U ' 7--, """" OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ 10_ License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
cr) () I am exempt under Section , B&P.C. for this reason
LO
O N Date Signature of Owner
0)CL Z WORKER'S COMPENSATION DECLARATION
C Cc I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W 4- compensation, as provided for by Section 3700 of ;he Labor Code, for the
O Q performance of the work for which this permit is issued.
m Q U (,) I have and will maintain workers' compensation insurance, as required by
OU
Section 3700 of the Labor Code, for the performance of the work for which this
Il H permit is issued. My workers' compensation insurance carrier & policy no. are:
co Carrier S F oMp 1 J8 y1 Policy No. 1342457-00
a
J
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply wit : tlioselprovisions..5-1p'
Date: f '+ Applicants +n ^' • t` -
Warning: Failure to secure Workers'-Gomp@nsation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
q . application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property fo inspection purposes.
Signature (Owner/Agent)- /'r - Date
BUILDINGPERMIT PERMIT#
DATE VALUATION LOT 0110-'10'7 TRACT
Rfili3€9
74 .5
JOB SITE n APN
ADDRESS9.Ed.Y YL0,Oi0.JRY iP%&f q,aC' o
OWNER CONTRACTOR / DESIGNER / EN (NEER
PACUT'C HOMES
PA U EWa- T CA 92211
USE OF PERMIT
aT:? ET'ALMIIir` maty
PA(MilC %row"119
7.564 A COUNTRY C XM DR
PALIA DWERT CA 92,211
(I6q)4•0$-3495 .' C 3'U$ 61331
4M. .X, -S' 1:kARE)fN .SI001, WtZL — CITY STA:NC3.E4RD
5 FT. WALL,
4sn up
1CONIi'iRUCTION FEE IUM00-438.000 1211,00
j
OCT 0 8 2001
CITY OF L,A 01'IE3'iA
u'UB21'(WAII., c' ONS'X RUC'TROW .f UD ; `. _*1 CIWILT,
117,33 F)RE-P TID PTM
7;fY%'AI, PKIIlaMF;EE'..S VUE d'iCAW
RECEIPT DAT, Ei BY I DATE FINALED
974:25
INSPECTOR ?ar:
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings _ _ _
Bond Beam j)////Q f`
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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)
COMMENTS:
A10
el&46V !