0311-210 (BLCK)LICENSED CONTRACTOR DECLARATION t
I hereby affirm under penalty of perjury that I am licensed under provisions of
Imo- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
r- (Y U.)
W v ...
oZ r- Date Signature of Contractor
co 0 �-
I,- U C:) OWNER -BUILDER DECLARATION
W WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ 4,e ) 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 licer's�'ed
contractors to construct the project (Sec. 7044, Business & Professionals '
Code).
U-) () I am exempt under Section , B&P.C. for this reason
N0 0) /Date Signature of Owner
CL Q WORKER'S COMPENSATION DECLARATION ,,77
QI hereby affirm under penalty of perjury one of. the following dectara�io�ns: 1 '
Cc
p () I have and will maintain a'certificate of consent to self insure for wor rs- -
X U compensation, as provided for 'by;'�S.ection.. 3700 of the Labor Code, fo� the
mJ _J performance of the work for which this'permit is issued.
Q U ( ) I have and will maintain workers' compensation insurance,. as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il M F- permit is issued. My workers' compensation insurance carrier & policy no., are:
Nr Z Carrier Policy No.
co 5
n CY
J (This section need not be completed if the permit valuation is for $100.00 or less).
(f ) 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
1 subject to the workers' compensation provisions of Section 3700 of the Labor
•`•l7 Code, I shall forthwith comply with those provisions.
,-'bate: Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer-to"criminal penaltiesand civil fines up to $100,000, in
addition to the cost of. compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on .his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �'"2" ��-�+-:--:.r--Date°���
. y� t4,u
-BUILDING_PERMIT PERMIT#
0311-2.10
DATE QQ yy '�VALUATION �q @~ LOT TRACT
7
JOB SITE
ADDRESS 5.1,.$"AVXNJJD A C1% N.%aA.
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
MASCOR0, JEMS
OWNER BUILDER
51-620 AVF, CARRANIZ Fs
L.A QCTni rA. CA, 92233
i C'ELO
USE OF PERMIT
GMMI AL 1�il br7C�
100 LP 5'BLOCK. WAt.%.. VM CITY S'L ANL`+l4bZn .ALONG NC?itTH Ph -
5 FT. WAIL 1010D IX
ES14TFil+ TED C01%, OF CONS'd'.I�TMON
21165M
COWSTRUCTI011 FFA; 101-000-418-000 S34.00
NOV 2 0 2003
CITY of: LA OUINTA
FIN f�i C -121=PT.
SUB -TOTAL CON;3TRUC" 101 .AND ixf.A4 CF-WCT',-
$54.00
YMB PRE -RAID MS
S0,00
RECEIPT
DATE �y
BY
r ..
DATE F ALED
z zz o3
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
OX 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 - In'.. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond I
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final o 5 1
Gas Piping
PLUMBING XPPROVALS
G t
ElectricFinal
Waste Lines
Heater Final
Water Piping
Plumbing Final I
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
Fixh)res
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:, .