0011-070 (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
,Date Signature of Contractor ;4 1; -
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.
(/) 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.
EXEMPT
(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 shall4orthwith comply withtl!te�provisions.
Date: ;,5 "` Applicant
(V
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 w;iose 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 fq%inspection purposes.
1rf/LIM
f 2
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION
LOT (101 1-07(j TRACT
nID-f7
i8 AX2. t _2
JOB SITE
APIN
ADDRESS
53--:575KV i)ti, RUB10
774-112,014
014
OWNER
CONTRACTOR /DESIGNER / EN (NEER
PO k' OX 8 34"
5137 Q A'VMRDA B.f�P.Ap`f..,p.A S
.TAQ-MWrA.'
Ok 92253
LAQUINTA CA. 922S3
(760)564.29653 M74
6255
USE OF PERMIT
92 LY. 4 (H) M, RDIN3 WAILIL
(R.FTA.(NNQ) . MIT 0N1,Y
4 Y,T 4YR1i...5d
Q,00 LF
Cl�` ST'RUC ION FFX
101 'ekf,-49 C-000 �4.Ot1
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Nov 13: 2000
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$35.00
RECEIPT
DATE
BY
DE I L
INSPECTOR
V
INSPECTION RECORD
OPERAT@N
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs !I
Underground Ducts
Forms & Footings 11
Ducts
Slab Grade I I
Return Air
Steel le
Combustion Air
Roof Deck JJ
Exhaust Fans
0. K. to Wrap jJ
F.A.U.
Framing 11
Compressor
Insulation I w
Vents '
Fireplace P.L. it
Grills
Fireplace T.O. JI
'Fans & Controls
Party Wall Insulation;I
Condensate Lines
Party Wall Firewall if
Exterior Lath
Drywall - Int. Lath I
1Z
IJ
•
1!
Final
Final li
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs ] (�_( `f —p
Electric Bond
Footings II f
Main Drain
Bond Beam it _ _ �Q�
Approval to Cover
Equipment Location
11
Underground Electric
11 j
Underground Plbg. Test
Final �1 �Z�(�( ��
Gas Piping
ING
PLUMBPLUMBING APPR`\OVA LS
Gas Test
e
Electric Final
Waste Lines ]
Heater Final
Water Piping I I
Plumbing Final
Plumbing Top Out 11
Equipment Enclosure
Shower Pans jJ
O.K. for.Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection I I
Encapsulation
Gas Piping ]
Gas Test I
Appliances II
I I
Final
]'
COMMENTS:
Final I -
Utility Notice (Gas)'!
R
ELECTRICAL APPROVALS
Temp. Power Pole 1;
Underground Conduit
Rough Wiring Jt 4
Low Voltage Wiring
Fixtures {
Main Service ll
.
Sub Panels I
Exterior Receptacles
G.F.I. ];
Smoke Detectors I I
Temp. Use of Power
i
]I .
Final I [
Utility Notice (Perm)