0010-182 (PAT)f LICENSED CONTRACTOR DECLARATION
I hereby ariirm undsT penalty of perjury that I am licensed under provisions of
_,G apter 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
V111 D013 24
Dated e Signature of Contractor
m
OWNER -BUILDER DECLAR TION i
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.
STATE. FUND
(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 s all f Ahwith comply with those provisions. ,
Date:, Applicant : 701,4 .
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 to a-
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.
i 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 or inspection p Vrqoses.
Signature (Owner/Agen " Date
�s
BUILDING PERMIT PERMIT#
DATE* VALUATION LOT TRACT
y 13 / p�'WZAQ
JOB SITE
APN
ADDRESS
W_ AWINIDA.RUM10
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
53.7 15 AVM .U)ARUB10
666 s71CtTROL.ON a;►LVE
C.1tS Q"t.3"NTA 92253
C;COE'%AMR.','A- CA 92,626
(1114)M-5493 CBU 4240
USE OF PERMIT
.128 c,JV. "tL.fJllttAWOOD L ATTIC"X PAT IO C:OV e'r` o.cno a san)1$1s"
PFA PUNS VOL.Y
POsRt;l':fIPATIO 125.00 S?
SUMC:ONS7`�€Uf,;T1014,PEE 101-(J0 1 $1.00
I h� Cr& C:.K. 101-000-4339W
SUOAlO MOTION FEE - MID 011-0M,M _000 $.50
N.
VITM-WrAL GONSTRUC'"LIOR Ate) PLAN CITELI:
$48.15
USS M -PAID ITFS
• �AJD
$0.00
•Aia/.M1.CAL .S.pE91SY.trl.T A -!I MS JAM d'04f •4
$68.11,
OCT X19 2000
vt- L AQuita
RECEIPT
DATE
B'"
DATE FINALED
INSPECTOR
INSPECTION RECORD
a OPERATION
DATE
INSPECTOR'
OPERATION
DATE
INSPECTOR
BUILDING APPROWLS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
Ducts
Slab Grade
Return Air
Steel r
Combustion Air
Roof Deck ;,
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation t'
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation?
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
A�a,. s •�-s- o Z
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 1
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out 1
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test r
Appliances
Final
a:
COMMENTS:
Final i
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole 1
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptaclesd
G.F.I.
Smoke Detectors
Temp. Use of Power j'
it
1
Final II
Utility Notice (Perm) 1
a
a
GAS HOUSELINE APPROVALS RELEASED TO THE GAS COMPANY
Clearances laxed at or after 5:00 PM will be processed the next work day.
"Please use a new sheet each time when faxing releases."
The Gas Company
Centralized Set Desk
Redlands Customer Resource Center
Phone (800)228-7377
Fax (800)577-3999
Fax (909)307-7050(51)
Date: to • 3.Oz
Pages:
From: 1A
Phone:
Fax: _
Contact:
Building and Safety
TRACT
LOT/
BLDG
HOUSE
STREET NAME (Note if release if for
address different from permit address,
I.e. rear unit.)
APTIUNIT
CITY
PREVIOUSLY PHONED/FAXED
DATE & TIME, TO WHOM
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