0110-037 (RPL){ t LICENSED CONTRACTOR DECLARATION
�- I hereby affirm under penalty of perjury that I am licensed under provisions of
H _Cha( ter 9 (commencing with Section 7000) of Division 3 of the Business and
fV W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Data
CY LO 789540 BbE'a3
�, - r,
Z Date 1 � "�?1 Signature of Contractor ��✓�
CD 0
J U OWNER -BUILDER DECLARATION
W — WW
FI hereby aff inn under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z( ) 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 licensed
' contractors to construct the project (Sec. 7044, Business & Professionals
Code).
Cl) () I am exempt under Section , B&P.C. for this reason
LO
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
CL
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
FZp () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided -for by Section 3700.of the Labor Code, for the
O _ Q performance of the work for.which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
b(-).: Section 3700 of the Labor Code, for the performance of the work for which this
11 rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
`t Z Carver WEATF YfUND Policy No. 10440Ir,3 20227+
Cb Cb ry=
V
J (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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with th`s +provisI s.Av1
Date: 4 Applicant �` •�
Warning: Failure to secureWorkers' 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 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 4
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for�p
inection purposes.
s, 14 f
Signature (Owner/Agent) gym°¢% ..-� Dater/7 -�?
BUILDING PERMIT PERM0111114W
DATE VALUATION "5.W LOT TRACT
JOB SITE
ADDRESS SAVd...Jf4d�tira43CA�atilaiSLieS
APN r
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ALL ATAMICM, HOME 1XIM-DERS WC
ALL fildMCAU HOW, BM DERS WC
7fr�:.5 PZ,C1PID-,MMM
76995 F,Q:itTIDAAMME.
PALM�:D:F MRT CA9L2 a 1
PAIL :D 'EB'T C' �,. 3Au 21
(76OY200-0277 CBLft 6373
USE OF PERMIT
I'd. UIQ AF..ARMI AxAEtixlEM o3HAL1, BE IN PIA -CF AT PRF -PIASTER
[NOWTION. POOL ZQUIPMZN T ENS°i,tAUR.K NOT .T14CF.1 DED.
PC+O1„ AND/OR SPA 14;3
Ns' -A" D COST OF Q''01011MURON
6„' .00
planar TRY; g mmaty
MM4 CHECK NF?8 112150
C ONII'%'RUCT10N FEE'1 01-000-Q. t 9-0011 $90.00
Y+��E� TIANICLAL F KK -- POOH_ 101-04, 00-%`1-0 624.00
! fl�"'I'it.TrE� •• 4�O at. FD7i�(>ik�f-Llai)-g.Cn
D ,
OCT u 9 2001
CITY
OF LA QUINTA
FIN,411lCE DEPT
a 5VB-S. M�,'-iH61 CO/Y►�7 k'A'ti%cF'.Ac).l� 2LiVpPLA.1.tl +...•1m7.4
YKE,,PAM R00
MOO
:!J
°I. IAL FERMV FKCS 1"ME now
NY
Ur 14N)' .
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
h
-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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I 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
=U2
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:
' V
` R"E-INSPECTION. FEE. OF
WILL Bt CHARGED IF THE APPRuvtl
OLAHEN SAND 10B CARD ARE NOT Oiv
��SPEC FORA SQ, EDULED
�O WEPTIA4 -
�) Cn
z CITY 'OF L-A
BUILDING & SAFETY' DEF';
t°voL
APPR k
FOR CONSTRUCTION !
BY
w
M