0002-071 (TT)LICENSED CONTRACTOR DECLARATION
I hereby affirm undl�t� penalty of perjury that I am licensed under provisions of
o mencing with Section 7000) of Division 3 of the Business and
Chapter 9 �;
Professionals Code, and my License is in full force and effect.
Licens6503S3 tic. Class Exp.:D077131/201
r
/ate Signature of Contra
OWNER -BUILDER DECLARATION'
I hereby affirm under penalty of perjury that 1 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 ..
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.
(\)',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 FIZ54MOIN'TCOMP LINS' Policy No. ygNTM143",0- 1
(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 shall forthwith comply with. those provisions.
Va%: '`L-/ t /.., . Applicant..
Warning: Failure to secure Workers' Compensation verage 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forinspection purposes.
)
Signature (Owner/Agent��'' __Date:L/2
A0f
BUILDING PERMIT PERMIi#3f4�ijr
DATE 02103f00 VALUATION $3,000.00 LOT TRACT
JOB SITE 79-124 HIG'MYAY I II APN - -
ADDRESS
OWNER CONTRACTOR
�� S �� i� CONTRACT�O+R / DESIGNER / ENGINEER 1
,iic44✓.ri. iir._.i0r._) i11LR1K cJ}: ��P.jJ:�i�i4iirivi �t'�.rv�} aw �iR+T�"ii�i.�-1.�.�tial a�i�,l�v i�4✓� '.i�
is2'3'i%3S`.!'1N'AVF.-N JI StJI"M F 741- 941XNivDN PLACE. SUITE PI
SA:N'1A ANA CA. PALM DESEE I CA. 92260
(?60)340-0194 CRI .1.4 30126
USE OF PERMIT
'VAj.,iM-110N
3,M.00 1113 '
.a �iS 11A1A r4,J",% C SS OF i" OP -1:3 B RUC171U1Y � w1�4Y�ik.V�7
PERMIT FEIR, Su% 1114AR
'.f.` WIP tit N8'Y1t1IUfIC3Af TRA.U,.W .101-()00-423-000 $200. CIO
S1 JB_' O'TAT1 C;0K,91Rf IC:TYXq AND MAN CHECK $2fx',.1)t)
LESS ME -PAID FET,,S $0,00
RECEIPT I DATE
W—A
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION l DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
COMMENTS:
I Final
ELECTRICAL APPROVALS I
Temp. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
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
Gas Test
COMMENTS:
I Final
ELECTRICAL APPROVALS I
Temp. Power Pole
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power