PLBG (0108-263)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 effedf�l
License # Lic. Class Exp. Date
04 3 Y2(
? 422155 Da
pate Signature of Contractor
OWNER -BUILDER DECLARAYION', -
hereby affirm under.penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ), 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).
1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business-& Professionals
Code).
O .1 am exempt under Section B&P.C. for this reason,
Pate 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 wh ich this permit is issued. .
1,have and will maintain workers' compensation insurance, as required by
Section 3700 of ithe Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier' . f . . . . 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'. compensationprovisions of Section 3700 of the Labor,
Code, I shall forthwith comply with those provision§
Date. - ' . C-/,�. 'Iva—
Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,00, in
addition to the cost of compensation, damages as provided for in Section 3706
o6he Labor Code, int6resiand.aftorney's fees.
IMPORTANT Application is. hereby made ' to the Director of Building and.Safety
for a7'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, indemnity
A 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 cf 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.
;Signature (Owner/Agent) Date
.BUILDING PERMIT PERMIT#
DATE VALUATION LOT 010? •463 TRACT
JOB SITE
APN
ADDRESS
A WAVATMO
.77348440"/
OWNER
CONTRACTOR DESIGNER EN (NEER
MR. & Wa RICE, VVI Munt
ROTO ROOMIR
511900AM NAVARRO
7,96 17, ErME �rr, I
I. QUINTA CA 02253
M.Awr CA 9254'1
cmfi 1%0
USE OF PERMIT
PI-MMING
512VER 1400K -11P, N74n.7CA11ANDON QZW-MOD PROAPVT M1.03)
VAIXATION 141
X61 M'"11M MR, 0:101 CONArMTH.MON
1,6P.-%00
YkImEr ME firama"Hy
SEP 18 2001'
CITY OF LA QUINTA
FINANCE DEPT.
LOS PIM -PAM ITY33
$0.00
MY, NOW
RECEIPT
DATE
BY
DATE FINALED
INSRECTOR
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
I
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
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: