0208-344 (RC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I'am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Divisiom3 of the Business and
Professionals Code, and my License is in full force and effj,,ti.
License #a��t `itra Lic�-.•rClass 'K7�',EXp. Date
A nt
Date Signature of Contractor
"' V•� .�" ,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 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 g& Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date 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 workers'
compensation, as provided for, by Section 3700 of the 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 -INAPT j' Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( of I certify that in the performance of the work for which this permit is issued,
I sliall 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: 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 Safety6
for a permit subject to the conditions and restrictions set forth on his--
application.
is;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 pe-rmit 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) Date
PERMIT #
BU'ILQI,NG PERMIT =-,1,
.�,
DATE VALUATIONy LOT. a, TRACT
a
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
18.267 HWY 131
43-719 MMII,GOLD
USE OF
'y�P1,7E�R�M}�IjTy { Cg A ( MODEL
C.Cs1vlIMUi CIA1'.. Tf RE:db'tUKAU, RI?:I.C2C.FsTZ 0WIC E xPA.0 E h e 2?7L3:17'WI G
ST 011AGZ r541RA,
'V.h IWA,TJON 1000.00 118
>;iS•
1'1 Ahl CHEM R- E, 101-000-4119-3,118 U.",1
td4"aNS TR.UCT 1014
$3�,C:I� t4N9C.e $a : b1 wibJC�I M3.000
&LEC"'f 1"U CtT L FU 101-000-426,000 $14.50
STRUNG MOTION FIX - COMM, MM,, l 00 -000 -?Al -000
13't3:1;', -TUU COAs 'MUMOR �t�:t� �'�1t� C�i��•t"'1�:
S112833
3
IX $0 FRE -PAM FrUNS
$0.00
'1<'�3;•:P1;:l"".ITT ]':i;_xN �C3'`C�' R•CA1k
l3
CITY OF LA QUINTA /
FINANCE DEPT. /
RECEIPT
DATE�DATE
INSPR
INSPECTION• RECORD
OPERATION
DATE
INSPECTOR-
OPERATION
I
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 4+
Underground Ducts
Forms & Footings
Ducts
Slab Grade F
Return Air
Steel "'
Combustion Air '
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U. .
Framing - /7 G Z
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
1
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
-�Final
Final D
BLOCKWALL APPROVA S
''POOLS
steel
'
-SPAS
Set Backs .
Electric Bond--• -
Footings ?
Main Drain
Bond Beam
Approval to Cover
+
Equipment Location
i
Underground Electric
Underground Plbg. Test
Final
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
i
Gas Test '
Appliances
' -
Final
Final'
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: r
�EBiwtr Hs�pt2�J 3//%/03''
'
IN.