0203-227 (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 Exp. Date
63g °Irt 13.1
Date `w' Signature of Contractor
OWNER-BUILDERCLARATION
/ ;
I hereby affirm under penalty of perjury that I am exempt from the Contras or's'-
License Law for the following reason:
( ) I, as owner of the property, orfri y employees with wageyas their sole
compensation, will do the work, andtthe structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). �r
( ) 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.
(,) 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:
Cartier STATE MD Policy No. '22902-W"671
(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
j Code, 1, shall forthwith comply witl those.provisions.'-�11r-—y,;�.;,,,_; e:-, 1ti't( :Y.,
Date: "�' `r"� Applicant
`'-Warning: Failure to secure Workers' Compensation coverage, i's� Lin lawful an
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 fiereby 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
'.. j L.
f Signature (Owner/Agent) 'Date`"
PERMIT#
BUILDING PERMIT
DATE e r ,," _VALUATION LOT W-� -22'7 TRACT
4122102
JOB SITE
APN
ADDRESS 55 2 A VE M. A PUB 10
_
OWNER
CONTRACTOR/DESIGNER/EN INEER
-
r" L,'i'Z DTD L VFNTIJRYX, WC
LWR DEL VM41`(11 �,'S, BIC.
78.120 CAUL? ? XWO SUME 204
7 8.120 C,t47.LE MADO VIT'UR 2N
L A C1RTlii►`TA CA =313 _
LA QLTXW A Chi 92253
(°760)5f,4-1566 CBL# 859
USE OF PERMIT
M p q ygUWO
GE
I;! LF. 55' 81.AClC Wl�,LL,, ! I LF. A' Bl.QOK al�f3l,L C!'1Y:5TA✓3d!),F:�LL9
Y
� ter. WALL 81,00 LF MAR
2 `5 2'Jti2
4 Fr. WALL 11.130 1?
®FLA,Q . �►
G '.
ESMAT COYX OF C®!49111WIC'MON
AS,
CONSTRUCTION FFM 101.000.418 -•-WO
311B• -C( fAL t:;Mt8rXXUCfrl0N. Y4D I L1. N C_ h- 0.K
LESS PRE -PAW RD!
S $0. c3t1
'TOTAL PIMMYXElr DDENOW OW
&11511119
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD- - -
OPERATION
DATE
INSPECTOR
OPERATION
DATE
IINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Duds
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
steel
POOLS - SPAS
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 -
1
Appliances
' ..
Final
q
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:
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