0203-092 (MISC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9. (commencing with Section 7000) of Division 3 of the Business and
F"ifessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
207 1 36 C.45 D38 CIO 04,'W(
,Date Signature of Contractor
OWNER -BUILDER DECLAR TION "' r� /V
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'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(4)s1 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 Policy No.
(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 those provisio
Date: r ski /� ,J 'Applicant'/%' iw y
Warning:Failure to secure Workers' Compensation coverage is unlawful and
shall subjecf an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees:
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject -to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to; & shall, indemnify
& hold harmless the City. of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for Inspection purposes.
Signature (Owner/Agent) 77 :l�R ��,'��w s .-=- -Date ~� h �\
k
-BUILDING PERMIT,;,PERMIT# - -
DATE VALUATION LOT' %4F�-i}Qr.$ TRACT
Os/gJ�i12C5t �75'LE�t31�,�t3
JOB SITE
APN
ADDRESS
W. 1.1.x pox n1'a.°HAFT,Y
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
omT i ORG01410
46120 CAMAOUN
`tip dtx�'CH0?MW.AGE CA 92270
INDI'O C° A- 92,201
(76o;3o.3566 CM4 223
USE OF PERMIT
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RECEIPT ,DATE/
�i
BYe
DATE FINALED
INSPECTOR
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
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 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
�y
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.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
IMPSTj��.c�l,
r
SIGN CO.,INC
46'-120 CALHOUN 5TREET
GA 92201
(760) 347-3566
FAX (760) 347-0343
CONTRACTOR5 LIC.#
207136, C45,C10, C61
B U 51 N ES 5 NAME:
tPATE: 1-�� -2001
This is an original unpublished, drawing,
created by IMPERIAL SIGN. It is submitted
for your personal use in connection with a
project being planned for you by IMPERIAL
SIGN.
SIGN. It is not to be shown to anyone out -
side your organization, nor is it to be repro -
duced, copied or exhibited in any fashion.
CU
CUSTOMER NAME:
DRAWN BY
TORRES
WORKMANSCOMP#
1424837-99
MAIL ADDRESS '
PHONE NUM6EK
CITY LICEN5E #
1345 98-01484
L
LAN LORD APPROVAL
1 JOB LOCATION:
FAX NUMBER
5tude/screws
epoxy into rock 51'ECIFICATION5:
APlanning Comn ..,,,_....,�,.
12" I11uminatedKover5e ChMr ra*J 5&&
Conduit & Power box Face: t -Community Dev. Dept, �--�—
Painted to match initials —o,,.
the rock Retu rn o: Case NO. 'G
tC'6 ca ey Tratioformer5 to be remotel5~r1 ed behind rock re uired.
nBU
OF LA UINTA ower to be by others v With ConditionsING & SAFETY DEPT, ettering to be mounted to rock a5 required.
This Is a original unpublished drawing created by IMPERIAL SIGN, It is submitted for your personal use In connection with a project planned for you
by IMPERIAL SIGN, It is not to be shown to anyone outside your organization, nor is it to be reproduced copied, or exhibited in any fashion
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