00-5048 (SIGN)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter * (corr;�encing with Section 7000) of Division 3tof the Business and
P'rofessioriA's Code, and my License is in full force and effect.
License # Lic. Class t `Exp. Date
r
7a�27 C45 �il{ ' 10/3l/2Z
Date �' r + Signature of_Contractor� /`�`
OWNER -BUILDER DECL'ARATIpN
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 & 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'
compe/sation, 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 STATE' FU14D Policy No. f56YffA3
(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 manne'Xso as tobecomee//subject to the
workers' compensation laws of California aV agree thatYl/should become
subject to the orkers' compensation provlslons of Sectio .3700 of the Labor
Code, I sh 11 orthwith comply with those�p`rovisio ss ✓ —�
Date:. ApplicantIf 7
Warning Failure to secure WorkersCompensationoverage is unlawful and
shall sutlect an employer to criminal penalties and ci it fines up to $100,000, in
addition to the cost of compensation, damages as 4rovided 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 subject pefmit 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 buildi g
construction, and hereby authorize representatives/of this City to enter.uron
the above mentioned property for inspection purposes �i
if
AO
Sgnatu'rer(Owrier/Agent): r "°" -Date '=
BUILDINGPERMIT PERMIT# 11:.1
DATE VALUATION LOT OOOS-048 TRACT
JOB SITE
APN
ADDRESS 7 'SI -TW- AWAY1YA
..
~
OWNER
CONTRACTOR / DESIGNER / EN (NEER
T,O ,S WIMWA",
REYNXR SIGN &, ,T ICf1-! IWC+
78-8163 WGRWAY 111
3 ARCIL1:.A
s..P..QY1INTA. CA 92233
RANCHO SANTA MM CA 92638
(944)888-0808 CIDIA
USE OF PERMIT
i
MISCM— AXIF.OUS
(1) fQ(TERIOR.WA.I..L MOUNTED IN EPMAL f,JAXMiNATED SIGN PER
.APPROVED PLANS 014L t - PEP, SION APPLICAIT'IOX 20004071FUT'E DEV
97.605.
VA.LUA:TION 1Z
.F.b 4 t3'I17) COST f ' ' CONST . Jic7C%C)1�3
4,100.00
Y
PM.M,r ' FEE SUMMARY
CONSTRUCTION FIE 101-000.41.8.000 M.00
EL,E;CTRiCAL VES 101-000.4.20-000 $igloo
PLNN CHECK FRE 101-000-09-318 $46.80
SUB-TMAL COMMLiMON AND PLAN CMEMC
V36,80
1M5 PRRi PAID MS
$0.00
TOI'A1L+ PERBUT I' •s DUE
$.t?A5M
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
U7�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
F rms & 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
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 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
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: