RPL (0304-105)_ ^ LICENSED CONTRACTOR DECLARATION'
| hereby affirm under penalty oiperjury that | mm licensed under provisions of
Chapter 9(commencing with Seotion.70000fDivision 8cxthe Business and
'
Professionals Code, and myuoonoeioinfull force and effect. .
~
License # uco/axa Exp. Date
6563 2�
I - -I t7jJ;".i /(V
uu,oSignature of Contract '~
' ^ '
OWNER -BUILDER DECLARATION
| hereby affirm under penalty cv perjury` that |omoxamp�ommoCnn�oumroI
�vonooLaw �xmo�Uow�gm000n
( > |, asowner ofthe property, or my employees with wages as their Sole
compensation, will do the work', and the structure is not intended moffered for
sale (Svx.,v°°.Business uProfessionals Cvov).
'( ) |.aoowner oxthopmpvrtyumexclusively contracting withn
contractors to construct the. project �o� rmw. emuneoo�m
Cod*). ' '
( > | am exempt under Section ' . o&PC. foxmis,oaoon '
oom Signaturem Owner '
�
WORKER'S COMPENSATION DECLARATION
`
| hereby affirm under penalty of perjury one of the following declarations:
. have and will maintain " certificate = consent oself-insure for workers'.
oumponaaoon.`aa provided for by Section 3760,nf the Labor Code, �,Vm
performance or�owomhvwh�h��ponnh��uued. ' �
and will maintain workers' compensation,, insurance, as required by
permitSection 3700 of the Labor Code, for the performance of the work for which this
_ is issued._'compensation— insurance'carrier & policy no.�-are:
Carrier TIVN7re, COMP104SATI Policy No. , ' 0464168-3U3
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(Thio' $100,00 or less).
I certify that in the perform,a,nce.of the work for which this permit is i s4sued,
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 S�cti6n 3700 -of the Labor
Code, I shall forthwith, comply with those`;p1rovisipns
Date: Applicant w
Warning: Failure to secure vvomom, Compensation coverage is Unlawful
shall subjq.�t 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 Safeity
for a permit subject to the' conditions and restrictions set forth on, his;
^ made & eacli ISerson 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 uoaresult ovthis application becomes null and void if
work �nm�mmo�o �min1oou�s�m�m�io�u�o.�o�h
ponnn. or cessation ofwork for 1oodays will subject permit oocancellation.
| certify that | have read this application and state that the above information io
correct. | ugmo mcomply with all Qty, and Gtom |owa relating mthe building
oonxoumion, and hereby authorize representatives ofthis City menter upon'
the above-mentioned property �p(ihspection purposes.
Signature�xwno�AgonV Date '
BUILDIN PERMIT,
DATE; VALOAT16N
ADDRESS VW.37f)VD.RTV;- YAW."
OWNER
CONTRACTOR DESIGNER I EN61NEER
.(7619)3981.9222 CTIP 00M
USE OF PERMIT
L TF PL
5F T. WAIL
MAN CliBIVIKIFFS 101 -POV,43NI 18 $1 i'V8.
C0!i2V UCTIMI FEE 181-000
19-000
FOAPR
-1 2003..'
CITY. OF LA QUKT_A:
FEES"DMI. NOW,
RECEIPT
DA/TE
E� FINALED
TOR
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.
Griffis
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test TZ -5-7-5a
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 S
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: