0105-273 (BLCK)-
_ LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
N , I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT 010&2,7.3 TRACT
c'l ;LU Professionals Code, and my License is in full force and effect.
License Lic. Class Exp. Date �` °6'•�►',�3� �"�°®9
O � M JOB SITE APN
ADDRESS
t --W r` t 595754 H 1 C9 Tom 54-945 A.WNDA C4RR 4NZA 774-•294-022
Z Dater��ignatureofContractor 9 OWNER CONTRACTOR/DESIGNER/EN (NEER
CCD O- p�M �- "'~'~
J I.—
cn OWNER -BUILDER DECLARA ON ATAX.19CM&EVAPM PAZ C-010,W(MONCO
W W I hereby affirm under penalty of perjury that I am exedmpt from the Contractor's 52-M AM,jljp/. IADI'j )OZ,e . 52-993 AVENUDA-AMMOZy
1,— a License Law for the following g reason: LA qf7IV.3T.>� CA922 53 LA QT:Tlfii'�'A CA 92253
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
����` �23 '' Tft 5�7
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &Professionals GRIMMpl0(IMG
Code). 7y.
Cl) () I am exempt under Section , B&P.C. for this reason 150 L4V 1�.�",',"AININNW` Cu' RDEN ?A►.A1d.
An
N Date Signature of Owner 0 LF 3r CMM4 4 WALL
Q WORKER'S COMPENSATION DECLARATION
p Cc I hereby affirm under penalty of perjury one of the following declarations:
p O 1 have and will maintain a certificate of consent to self -insure for workers' S Ft WALL 2MOD 14F
X w LL compensation, as provided for by Section 3700 of the Labor Code, for the
Oro J Q performance of the work for which this permit is issued. '
Q U () ,I have and will maintain workers' compensation insurance, as required by
QU Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
00 a STATE FY.� 229-011 UN IT 0015(1,00 lKSMO ED Codi' or C.O. AIRU i'i01-T 4,654.15
J (This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued, C0141$TR.UCTION FES 101-000-41.8-000 $73,00+
1 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
3 subject.to the workers' compensation prbv sior�s of Section 37 0 of the Labor
Code, I shall forthwith comply with thosef provi ions.
Date: OWFAicant
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 t
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 �i B-li`�,Y`�, , iM), MTIO �t D i�'1A CMrA'�:
any permit issued as a result of this applicaton agrees to, & shall, indemnify [ LESS PRE -PAID R q',;,3 $O.Go
& 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 TC _
work is not commenced within 180 days from date of issuance of such M AY 2 3 2001 MR"
w� ��UE ®
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 CITY OF LA QUINTA
construction, and hereby authorize,'�ep'resentatives o this City to enter upon FINANCE DEPT
the above-mentioned property for Inspection purposes.
F } �' RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) '�'_ t f +� . Date -' > = ",�
i
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
Set Backs j _ r
Footings �/
POOLS - SPAS
Steel
Electric Bond
Main Drain
_
Bond Beam
Approval to Cover
`
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
_�7/
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
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: