AR (0104-033)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.Business and
Professionals Code, and my.License is.in full force and effect. "
License* Lic. Class Exp. Date
f;SF19W f i 1 V.3 112 C
Date Signature of Contractor
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 / �°`. 7.%.��i'Signature of Ownerl
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 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 -Policy No.
(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 fofthw}th comply with those provisions.
War,nitig:=waiture'to se6ure-Wo'rk6fs'"C6m'jia'fiMi6n•°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 Applicationis hereby made to the Director of Building and Safety
for. a permit subject to the conditions and restrictions set forth on his
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, 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 inspection purposes.
(Owner/Agent), �` Y
Y (BUILDING' PERMIT PERMIT#
DATE r VALUATION LOT 01644�33 TRACT -
.4/ �/ � $�� ,�'T « ,4 3448
JOB SITE APN
ADDRESS ,A ��yy *��� ,yyyy 7.p 64&1914W7 d q
"' 9-M3 & O'.¢:.t�J:D'a�A ��r��.%d.6'.�J�..`T10 G74'�T'^�.1.95,—iW7
OWNER CONTRACTOR/DESIGNER/EN (NEER
THOMM-4 % &.Mi 4E: A# DRA&RX 11. 'E1V, JOxMMM L ON117Kft.'JCrION, INC.
49963 A`IF!NIDA Mt?MR0 1445 x3MMI!EWAY, IXTIM, 203.
wi,. ()a!•Jink CA 92,21513 PA� 1.01Ui+ GS CA 92262
(160)416.1144 G14TA00 5525
USE OF PERMIT
DI) SON
039 S.P. SZC`:11t1f3MOOR A0L31T1- 70 MI5 fi1NO MMR..i;Fe9MILY
DWELLING
CUST019 COAi:lTliUCTIONCOD By
EST)MATIM COW OF CONS-MC."XION
1'MCiX0TJU1dT10 Y.i<19 '. iF}]�OOi'��#1>I •OUL! i4�,a"4M1'
PL�RAN CHECK FLOE
1119RDR1,10911T..
MVICH4�d["NICa;;Ats.I1
r- :IZ 101-00, 421-000 g" .ot+
�M 7..;�...
IJVA J;f9!%'fa P: 1 Cbl -000 419-000 11M.08
1aTRO1' O NC1TIOW F REPOD 10 n '$1fi:
J11 JUL 1 1 2001 e%f
':CC's' PE*RM1*.i YENS DUE NOW
RECEIPT I DATE / / I BY
INSPECTOR
1191576150
$1,4139.04
- s,St1.00
INSPECTION RECORD
I OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
I Forms & Footings
Ducts
I Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
raming
Compressor
InsulationW!_V�z,
Vents
fireplace P.L.
Grills
fireplace T.O.
arty Wall Insulation
Party Wall Firewall
Fans & Controls
Condensate Lines
xterior Lath
rywall - Int. Lath
Final
'nal
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
S t Backs
Electric Bond
F tings
Main Drain
8 nd Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Fi al
Gas Piping
PLUMBING APPROVALS '
Gas Test
Electric Final
Mee Lines
Heater Final
W ter Piping
Plumbing Final
PI mbing Top Out
Equipment Enclosure
Sh r Pans
O.K. for Finish Plaster
S r Lateral
AA
Pool Cover
S r Connection
Encapsulation
Ga Piping
Gas Test ---N
Appliances
_
Final
_
I
Final
Util' Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Yottage Wiring
Fixtures
Main' ervice
Sub Panels
Exteri r Receptacles _
G.F.I.
Smokb Detectors
Tempt Use of Power
Final
Utility Notice (Perm)
COMMENTS: