BLDG (0108-325)" LICENSED CONTRACTOR DECLARATION
' - 1'hereby'affirm under penalty,.:of perjury that j am jfcensed under provisions of
Ham` 'r 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.
C M License # Lic. Cass �{ Exp. Date
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d Z r� DateSignature_ of Contractor,
J V CID-� '. < OWNER -BUILDER DECLARATION �
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I hereby affirmAUnder penalty of perjury that I am exempt from the ContractoraCt,
License Law for the following reason:
Z( ) 4; 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 Ito construct the project (Sec. 7044, Business & Professionals
Code), f
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O I am exempt under Section: B&P.C. for this reason
N Date;'' Signature of Owner
O C\1 J;' ; ,
U Q I 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 which this permit is issued. r
(,, have and will maintain workers' compensation insurance, as required by
S ction 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.
ik�t�i7C�.A'3'J�r�:
(This section need not be completed if the permit valuations is for $100.00 or less).
O t 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 Californ a, and agree that if I'should become
subject.to the workers' compensation provisions of Section 3700 of the Labor
Code, I;shall forth vy ith comply with those provisions.
Date: "a...�' %r .ir);Applicant I
Warning::Failure to secure Workers' Compensation 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. f
IMPORTANT Application is hereby made to the.Director of.Building and:Safety
for a permit 'subject to the conditions andrestrictions set forth on" his
application r
1..,E6ch 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
oany permit issued as'.a result of this applicaton:agrees to, & shall, indemnify
&* hold harmless the City,.of La Quinti, 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 a11,City, and State laws relating to the building .
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propertykfor inspection purposes. ,y t
Si nature (Owner%A ent)
r gUILDINGyPE�RMIT PERMIT# '
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MOO
AUG 3 0`2001
CITY OF LA QUINTA
,
FINANCE DEPT.
RECEIPT
DATE,{ + j %
BY '
DATE FINALED
INSPECTOR
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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
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
Gas Piping
,Gas Test
'Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Tem , . Power Pole
Undikground 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)