0107-137 (RR)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9
Cha (commencingwith Sion 7000 of Division 3 of the Business and z`
p Section ) DATE VALUATION LOT 0107-1 TRACT
Professionals Code, and my License is in full force and effect.
License# Lic. Class Exp. Date Q 16P°M65� .$���•
JOB SITE APN
'
V2008 �.�53 HIC ° aY 07131/2( ADDRESS R!;;�' 74-62 B 2I
Date Signature of Contractor r v� OWNER CONTRACTOR / DESIGNER / EN (NEER
c�
OWNER=BUILDER DECLARATION ,« � � c,s2�+ ,dyAR=R001MIGCO ANTY
I hereby affirm under penalty of perjury that I am exempt from the Contractor's X184211VY 1111 3 i 03 ONMR, AVEME
License Law for the following reason: LA QUWTA CA 97M53 G47TTAWMA CA 92626
( ) I, as owner of the property, or my employees with wages as their sole°ia���c►a
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).
O 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. X'
( ) 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 �y��{ t Policy No.
YA 5 ZGti7.1L A•
(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 tho-sg provisions. t�
Date: - d� Applicant A *4'wd- P. -29E7--I ►� 1
Warning: Failure to secure Workers' Compensation coverage is un
shall subject an employer to criminal penalties and civil fines up'to $1
addition to the cost of compensation, damages as provided for in Se
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building anq 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
construction, and hereby authorize representatives of this City to- enter upon
the above-mentioned property for inspe tion,purposes.
Signature (Owner/Agent) y �_. Date ?//'e• J
USE OF PERMIT
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REIROOF
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CITY OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE
1.71S3 PIM-PAMMMS
TMAL lyyamff Ms DIM, NOW
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INSPECTOR
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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 8 Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath '
Drywall - Int. Lath
Final
Final Eoti'-�� (
POOLS - SPAS
BLOCKWALL APPROVALS.
steel
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
COMMENTS:
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)