0103-092 (BLCK)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
Professionals Code, and my License is in full force and effect.
License # Lic. Class „ ter^ ^y Exp. Date,''" y
Date �!� •� Signature of Contract
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 & Professionals
Code). ,
( ) lam exempt under Section , B&P.C. for t`,,is reason
Date Sianature 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 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 tofhe
workers' compensation laws of California, and agre,_e that if I should become
subject to the workers' compensation prop of Section 3700 of the Labor
Code, I sh II forthwith comply with those provisions!. .
Date: -- 7,:. a 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 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 for
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 dayswill 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 authori;e•-representatives of this City to enter upon
the above-mentioned property,for inspectlor�,purposes.
Signature (Owner/Agent) f Date 31;1�2 % l
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS
APN
51—M5 AVICKWARUB10
OWNER
CONTRACTOR/DESIGNER/EN (NEER
. an. L'k��ti;};isd��3 �hC:�3�a't�'
��i.. AC7G;�`1�R�,i�A1':�1�'€� •
L& 0,D)ATA CA 92, M3,
LAQ!7NTA CA 92253
(70040945422 ll* 2387
USE OF PERMIT
10 Y,N' 0 CiA ".�5"ay�. N IR+.e4 LLP�SRCO
,) �5" R{;�3'rH WALL-ORCO
1Yt,P3'7
23;Lir'4`113,K)17A14r laNC OSURFoORCO
G` A' . WALL 210.00 IeF
5 ,fT t�', LIL 10.00 'L
4 FT. WALL 25,09 LF
:P-Myn nag rm-14h . Ry
101-000.418-000 $60.00
4h
MAR 1.2 2001
✓'AT T wi- vauNl
;y
SUB-1WAL C{:krMR00,1101T AND PIA14 r @ ,5C
$90.C'*
J .4A"AAL :E' 4 Uf M" DUE NOW
�tB
RECEIPT
DATE
BY
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
/
Electric Bond
Footings
Z�-r
Main Drain
Bond Beam
I
Approval to Cover
Equipment Location
Underground Electric
Final
II_I
((3 / D7 ��
Underground Pibg. Test
Gas Piping
I6
PLUMBING APPROVAL
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)