BLDG (0110-242)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty,perjury that I am`licensed under provisions of
AChapter 9 (commericing'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
1 WIN(
Date/, lej Signature of Contractor
y .
OWNER -BUILDER DECLARATION f
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 f
compensation; will do the work, and the tructure is not intended or offered for
sale, (Sec. 7044; -Business & Professionals Code). ;
as owner of the *property, am exclusively, contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code)..�.... r .
()' I am exempt under Section , B&P.C. for this reason
Date,: '11' Signatures of Owner
C'•' t fir.
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'
coinpen'sation,-as',proVided•for by Section 3700 of the' Labor. Code, for the
performance of the work for which this permit is issued.
( J *have and will maintain workers' compensation insurance, as required by
Section 3100 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier rX9JU 4' 1 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,
'?1shall 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 forthwith comply -with those provisions.
Date: i' /`xA ;T Applicant 4°)- tom+ -•4 --1. - "-
W. Warning. Failure to secur V o ker"� ormpensation coverage—E unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
,addition to the cost -of compen sation,'damages as provided for in Section 3706
' of.the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director.cf Building and Safety
for a , permit subject to the conditions and restrictions set,- forth .on. his
application.
Jr. 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 representative;: of this City to enter upon
the above-mentioned property for,inspection purposes.
Signature (Owner/Agent) F �. • ati�--- Date!
-•-:N4a.-..v;n.:-r'w4.v.w•4uns�....w..:n'wrw,R+"K'^"^••w1n
E3UILDING�PERMIT PERMIT#
y
DATE p0/22�'rp�" VALUATION dd'{ '•}� LOT + TRACT
JOB SITE _ r. �:1
.ADDRESS 452,�510.I.1VMPA 1wTA MUM0
APN •r•, r
OWNER �•t'
CONTRACTOR /DESIGNER
p•�yy'��
�/yENGINEER
S d 120 AMMODA kVA x1,0 .
5614a PD11`33L O IS'Pi.
92-213
YU `C F ,f
,
("i t3)369.71"ag
C: if 5315
USE OF PERMIT
d��
;5t£ k..� ;�'3®C%t4.4+.I�2�&d eq�Fii.,€.•.fJn,C~(? ''x'6;,Y�1Oee,t,I�
� '
6 Win% Syl3. ix $6,00 1A_ CITY
FL A
DEPT
CON10TRUC .101111 FEE a Lit -000.41 $,D00 $33,00
TUB -TOTAL 0,01. WdMON AND KAW.C;'k3 M,
S33.00
` s. rin-PAM rum
RECEIPT
DATE
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 BacksElectric
Footings �i C`
Bond Beam /� �Z �j.d !
Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final �Z 3r p�
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
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)