0112-155 (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 '
595754 BI C:9
Date -i ' + ) - 0 f Signature of Contractor �— -
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).
( ) 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.
( )h. 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 STATF, FIJ14D Policy No. 229-00 UNIT 0011 0y
(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 h those provisions.
Date: - Applicant
Warning: Failure to secure Workers' Compensation coverage is unlaw;fu and
shall subject an employer to criminal penalties and civil fines up to $100,000.1n—
addition to the cost of compensation, damages as provided for in Sectioln,37 16
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 o hi C,
application.
1. Each person upon whose behalf this application is made & eal 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.
mployees.: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-foInspection purposes.
Signature (Owner/Agent) i"- '� Date � 211 -d j'1/.
BUILDING PERMIT PERMIT#
rte. •.
DATE 1V21i" (X VALUATION i224W 0112—IM—IMLOT - TRACT
JOB SITE
ADDRESS �f a'1i.Si3� .Rr:
APN y
OWNER
CONTRACTOR / DESIGNER / ENGINEER
HIM.A CMIRILLO
PAZ. CON SMU ZION CO
53.220 MMI)A iZtTB10
52.995 AVENMA SVIYMOM
LAS°WIA CA' 52253
LA Q111br, A CA 92Z53
(764`}564.3023 Cmfi 55:7
USE OF PERMIT
GENERAL 1riUffZING
l'S L.N'.4' PRO.I�APIP� 1+,h7C:i,Gi.�L11ZJf, . CITY STAN DARD
4 FT. WALL 14.0 LF
ERTMAIT.D COST OF COM C? UCTION
224.00
CONSTRUCTION FEE 101-000-418-000 $is�,tTQ
.p
UF
EC 21 2001
rty Gi Lf*Qolti7 ih%
S119-7'O�'�'SI. �� C)A�S�S.i".i UC.'°t'IQN erii4�T 9 lDT C &' ' C.
$15.00
TMAL ][ AXAlllyr 11...E N 1)LYE hTC3W
s1 S>4�tF
1.. J'
RECEIPT
DATE 7 i
BY fC L�
DATAFINALED '
INSPECTOR
.y
II. INSPECTION RECORD
,
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
,BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I I
Underground Ducts
Forms & Footings 1
Ducts
Slab Grade 1l
Return Air
Steel 11
Combustion Air
Roof Deck 11
Exhaust Fans
O.K. to Wrap 11
F.A.U.
Framing Il
Compressor
Insulation If
Vents.
Fireplace P.L. It
Grills
Fireplace T.O. 11
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I
Exterior Lath I I
Drywall - Int. Lath 11
11
l l
II
Final
Final II
B�LOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs 11
Electric Bond
Footings it yL�p�/���
Bond Beam IC / Z v
It
Main Drain
Approval to Cover
Equipment Location
t1
Underground Electric
i!
Underground,Plbg. Test
Final 11
Gas Piping
PLU:MB.INW* PROVALS
,Y ::.. •:.
Gas Test
Electric Final
Waste Linea; `(t «;
Heater Final
Water Pipii§g.: ` `''fp
Plumbing Final
Plumbing Top Out 11
Equipment Enclosure
Shower Pans 11
O.K. for Finish Plaster
Sewer Lateral I I
Pool Cover '
Sewer Connection I I
Encapsulation
Gas Piping 11
Gas Test 11 _..:..f•s
Appliances
Final
11
11
Final II
Utility Notice (Gas)II
ELECTRICAL APPROVALS
Temp. Power Pole it
Underground Conduit
Rough Wiring II
Low Voltage Wiring I
Fixtures 11
Main Service I I
Sub Panels 11
Exterior Receptacles
G.F.I.
Smoke Detectors II
Temp. Use of Power
It
11
Final I I
Utility Notice (Perm) I
COMMENTS: