0402-277 (BLCK)1—
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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
Date
Signature of Contractor
OWNER -BUILDER DECLARATION
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 theproperty, or my employees with wages as their sole
compensation, will dofthe 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 & Profess als
Code) `a.
O I am exempt under Section , B&P.C._forr this reason
Date L A e 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 woykers'
compensation, as provided for by Section 37001of1the 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.
i
(This section need not be �ompleted 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,
1 shall not employ any person In any manner so ps to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions ofe ection 3700 of the Labor
Code, I shall forthwith comply with those provisions.
•Date: - ', �! Applicant_
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.
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 Wer sult 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) :'"' Date 7
BUILDING�PERMIT PERMIT#
(KM -277
DATE VALUATION LOT TRACT
O.1 V20C t9214- 7
JOB SITE
ADDRESS hRl FI�..�Itt'iC;A:_{�dklt4
APN -
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CIRiS'Tt>PMR 1 AGNE8 VAR MY
OWNER • B?1MDER
52.813 AV1.:.�l. DA C.ARIZA14Z.A
'LAA w'... CA 42253
USE OF PERMIT
G.'MFUxAr.
T7 L. V. CiA IIEN WAIA, O H10H
6 Fr, WALL 37,00 LIQ
EISTI ltrE 7 C+?)::T OF C•,OMIMMON
925.00
P s1 WT ITE S1.'f14U AR.Y
COMIRUCTJON 101-000-418.000 S"'00
FEB 2 3 2004
CITY OF LA QJrKfA
FINANCE
DEPT.
MB -TOM, 0014,17MUCTTON AND PLAW C13 C
$25.00
IMS PRE -PAID
$0,00
RECEIPT
DATE
BY
DAT FINALED
INSPECTOR
22-6y
4�
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final 1
1
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs _
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
r—
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
i
Sewer Connection
I
Fnrnn ld.tinn
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Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit I
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice