BLDG (0111-023)LICENSED CONTRACTOR DECLARATION ,
Wi , _ I hereby affirm under penalty of perjury tliat I am licensed under provisions of
Hr 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 License # Lic. Class Exp. Date
LU
Z ir� � Signature of Contractor
d
J UCID
OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury.that I am ezempVfrom the Contractor's
- ~ d f' License Law' for the following reason:
Z_ (`) 1,,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).
NO I am exempt under Section B&P.0 `for this reason:`;
O N Date Signature of Owner ' �!
(�
Iff Q ` WORKER'S COMPENSATION DECLARATION
'It C I hereby affirm under penalty of perjury one of the following declarations:
Lo0 O 1 have and will maintain a certificate of consent to self -insure for workers' .
x UJ LIL compensation, as provided .for by Section 3700 of the Labor Code, for the
'r.0 J Q performance of the work for which this permit is issued. r
fa QU ��)' 1 have and will maintain workers' compensation insurance,'as required by
O U Q ,. S 'tion 3700 of the Labor Code, for the performance of the work for which this
" a LO H permit is issued. My workers' compensation insurance carrier &policy no. are: i
- 't Z Carrier ''ST,¢�T S FU14U. Policy No.' . 3 19tt^f1r
CIS Z)
Q (This section need not be completed if the permit valuation is for $100.00 or less)"
J () 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 C9Iifornia, and ag ree�that if I should become
subject to the workers' corn nsatlon
y w
'provisions of, Section 3700 of the Labor
Code, I s�all forthwit complith'th'pse'�provisions !r
Dater!-T7APPIicant
Warning: Failure to secure Workers' Compensation overage is`�inlawful and
shall subject an employer to criminal pens ieb and civil fines up 1q,$1 00,000, in
addition to the cost of compensation, 'damages as provided for in Section 3706
of the Labor Code Interest and attorney's fees..
IMPORTANT Appllcation_is hereby made to the DiFector,of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.. • 1 7
1. Each person upon whose -behalf this application is made & each person at
whose request and for whose benefit work is performed, under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City -of La Quinta, its officers, agents and employees..
2. Any permit issued as a result of this application becomes null and void if
work is not commenced' within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• �� correct. I agree to comply with all City, and State laws relating to the building
,construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for'inspectfon purposes.
.f r
��. Signature (Owner/Agent) !� Date -�' -----
�,.._..
PERMIT
L
/j, BUILDING PERMIT`
DATE //� / : - VALUATION. F.Y�dD LOT TRACT
JOB ADDRESS 5k.2^'9&i A'A�iJKNTP3A k�4�%43!'p's1t
APN
OWNER FCONTRACTOR
/ DESIGNER / EN (NEER
4..
"6U 4"(:O R 1 41.11 R
PAWI.+t' IC TRAM OONITMUCE10,14
CA 942253
8 OCEMSIDE + CA 9?054
USE OF PERMIT
7 I. V'. 6' QUL)KH WALL,, 2.1,,V, 41 PV.0-PA14It n7CL4SUf%4 7N0TR
,, 6 FT, WALL
" d FT. WAI.,LL 121.00 LF
I:E1`i'P,°�€a,m), °:'C�'"�' or, �i o�9gr'�. u aN,�fon
- .(3
527
�'{ �� }}•�,� M �'•f Q�jf�`
RY
CYOl+fS`1'1$UCTIOX1r ? 101-000.418-000 $17.00
NOV 0 5 2001
OIV OIF LAQUINTA
FRAWFIDEPT.
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X 7.00"
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7
1 RECEIPT'
DATE
BY
DAT FINAyyEDo
INSPECTOR
-1�I
i � , t'�
` (;D
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_
Footings
�� � �
Electric Bond
Main Drain
Bond Beam
AE
Approval to Cover
Equipment Location
Underground Electric
Final�07/�
Underground Plbg. Test
Gas Piping
PLUMBING l� Pr�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)