MISC (0111-123)78215 Masters Cir
0111-123
-LICENSED CONTRACTOR DECLARATION
,I hereby affirm under penalty of perjury that I am licensed under provisions ofk
Chapter 9 (commencing ,jith Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp`./Date
Date . Signature of Contracto7.r le
r%
OWNER-BUILDER,,DE CeLR'ATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:.
( ) 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). '
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, .as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this -permit is issued.
,(I ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier FREMONT uOMPIENS . Policy No. SIB501•0600.03,20
(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 Te
workers' compensation laws of California, and agree hat• ifs should become
subject to the orkers' compensation 'rovsions of eotiorv13700 of thl Labor .
Code, I s II , h ith comply with-.thoso pro,, siop
Date: - Applicant' f :,
Warning Failure to secure W,o kcrs¢ Compensation coverage is unlawf, I,,and
shall subject an employer to cnmjfi'I penalties and civil fines up,to $100, 60
addition to the cost of compensation, damages as provided for in Sectio 6
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of. Building and afe
for a permit subject to the conditions and restrictions set forth o i; hrs- C
application. '.
1. Each person upon whose behalf this application is made &each per n 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, indemnify
& hold harmless the City of La Quinta; its officers, agents and employe(is.
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 al) City, and State laws relating to the building
n ". A
construction, and hereby autho ze represegta Ives of this City to enter upon
the above-mentioned 11property for inspec + m p gsg ,,,q;
1111 117.
Signature (Owner/Agent) 7 /'r Date
BUILDING PERMIT PERMT#
M_
DATE VALUATION LOT TRACT =
ap
JOB SITE.
APN
ADDRESS 144At`§'"1MRati CIRCI
.. ._ 1
OWNER
CONTRACTOR/ / EN h I N E E R
PNDREW WHIRCE (10KIPORPTI01a
ANDREW PIERCE CORPORAMON
N
44-835 :l')ERP CSA NY014 RD
44635 :(: MUI C:'AaIMON XD
W_'K Dr.. "MPT CA 92-26
IMLIA ADEMD'Iff CA 92261
'760)146-3226 CBV 03031
USE OF PERMIT
(i) `.t"1:`.f POi2A,,HY COId 'E'RUC TWN TRA.ILM Ct141,Y A5 Pfelt ildUP 2001.321
VALUATION MAN P;1
ESTIMATM COST OF CON MI:•UM: ON
".q • e't ' G1 5'4►'1 '# i i' 'lc ? ` 'k l';%;t ,l Z G3 Ufi fJ :d ML 1 2tlA.Ittf
OV 2 0 2001
uW—dF( . d u .
RHANCE DEPT
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LES 3 IF-PATD REZU
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RECEIPT
DATE ( /
BY
DATE FINALED .
INSPECTOR.
INSPECTION RECORD
OPERATION j
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
BLOCKWALL APPR_ OVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
EacTesttric nal
Wastelines
Heater Final
Wal: r 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: