BLDG (0108-192)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
'Chapter 9 (commencing with Section 7000) of Division.,3 of the B_ 5siness and
Professionals Code, and my_,License is in full force and effect.
License # Lic. Class Exp. Date
13
bate < ,'_ �'! Signature of Contractor ,1 f
OWNER -BUILDER DECLARATION1 •, S`,
I hereby affirm under penalty of perjury that I am exe pt 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,-B-usiness & Professionals Code).
(,) I; as owner of the property, am .exclusively contracting with licensed,
contractors to construct •the. project (Sec. 7044, Business & Professionals
Code). . I I I.. r
() 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 o the work for which this permit is issued.
(• ) I have a d will maintain workers' compensation insurance, as required by
Section 3700 o the Labor Code, for the performance of the work for which this
permit is issue . My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
11T.FsT FUND 1a30.9�A•6k
,,(This section ne d not be completed if the permit valuation is for $100.00 or less).
() I certify th t in the performance -of the work for which this permit is issued,
I shall not emp Ioy any person in any manner so as to become subject to the
Workers' comptlnsation laws of California, and agree that if I, should become
subject to the vJorkers' compensa>Ion,provisions of -Section 3700 of the Labor
Code, I shall fo hwith comply with thoseYprovisions. ~"`•
Dater /Applicant—
Warning:
Applicant �•
Warning: Failur to secure Workers' Compensation coverage i!Unlawful and
shall subject an mployer to criminal penalties.and civil fines up to ,$100,000, in
addition to the cost of compensation, damages as provided for ih--Section 3706
of the Labor Cod, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of,Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. t.
1. Each person upon whose behalf this application is made & each person at,.
whose request and for whose benefit work is performed under or pursuant t61
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes, null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
Correct. I agree to comply with all City, and State laws relating to the building
construction, and Hereby authorize representatives of this City to enter'upon
the above-mentioned property,ffor inspection,ebrposes. k`
Signature (Owner/Agent) r"r--- " Date"*" Z'
- BUILDING PERMIT - PERMIT # '
DATE _ VALUATION LOT f4 TRACT „
027,M)
JOB SITE
ADDRESS
APN
W-340 AMMIA, IMSPOZA
' 744X% Ml
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
• DAVID V wui .
T °A�1E`�L �:i��!°,'3 �t7���"�°rt�`lL.l'�U�3' r, ` ' • �;.
,1717 SO (H.FR OR
a 19 3 121114W f �•
CA, 92054
8 o .��}I�}J'I(I�J�(A7 ' CA
�9r2;0,l54
e r
USE OF PERMIT
' `,,7R,nf'7, + rd'.i1.I �L�J.G:.L JLV SY•
_.
T LI? OF 6' OARDW 'u�''.fiLL a$ 22 LP` OF df' b�l`vJPA1+IK ZWGL0f9'URE- r d'fi' Y
14TA'NDA,R.i
011'. WALL 7.00Ve
4 Vr, WALL 33.00 LP
CUNSIROCTION FEE 101 000-418-IDW
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.. SUSAXYM., COA1Y ttX7101�'AtTOPLAR C.k.Mi;:!C,
t'T.Ctt1
LS }I r P S
$0,00 %
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f.0 rAL YFJOC MIS ME ROW
AUG 2 9 2001
CITY OF LA QUINTA,�
FINANCE DEPT.
RECEIPT q'•
DATE
BY
DATE FINALED
INSPECTOR
�.•,. ..un...�... .. _ _-.e...�,.-.... .....-.+u �.� `'ti`� r.. �� - .._.•.�"'.�. ....- ...._ .... , __.. _ . wit
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
�
_
Si�
Ducts
Slab Grade
Return Air
Steel
Roof Deck
A • ..0
.�
Combustion Air
Exhaust Fans
O.K. to Wrap
v-�— _p
F.A.U.
Framing
— /O -p(
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
LQ Q — o !
57
Drywall - Int. Lath
Final
Final
.POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
g_3(—O (
S
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
tt
Equipment location
Underground Electric
Final
�( Z� , m
Underground Plbg. Test
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Q _ _ _
S%Heater
Final
Water Piping
{l�/a
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)