0104-077 (PAT)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
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
o pensation, 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). ,_-
() ,am exempt under Section B&P.C. for this reason
Rate ; e 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.
(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,
(hall 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
subjectf'fo the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: < Applicant
Warning: Failure to secure Workers' Compensation coverage'is unlawful an
shall subject an employer to criminal penalties and civil fines up to $1001,0001, i
addition to the cost of compensation, damages as provided for in Section 370
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and restrictions set forth on hi
application.
1. Each person upon whose behalf this application is made & each person a
whose request and for whose benefit work is performed under or pursuant t
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 purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ()1"077 TRACT /
JOB SITE
APN
ADDRESS
n0
OWpNE�(R))/t
CONTRACTOR //DESIGNNER EaN INEER
�ppddMM
to l7l,a, L1 Th1:VSN.�il��
J 00. ZVYLD/I
3 WO DUNE INAL W, RD
RUM(MA MIM CA 92201
c a MI.*
USE OF PERMIT
�60f2`l.�S`.fF.%9.T
A10 OV U1X1T S .t.D A' W
PO:R.C1-IdPaTIO 602,00 OF
FROM9MM COST OF COMTHU(MON
PLAN 121 -TWX 1TTE 101.000.439-3h18 M, 120
t;0'8dfy`it11i3C'f'1R i+? FTE d01-000-418-CCOO $108.00
�,,,,
S'>t ROHO 6t9,O i.034 ISE - oSi" 9 W 101 -=)-241 -000 CIO
W
APR 1 0 2001
CITY OF LA QUINTA
FINANCE DEPT
W11-71'C'+3'TE C:1" 7i1'mti3onom AI`11`l) mm Cm+C:kC
L.:I W PR..V PPXj MS
`0.00
TWAL Y10AMI'MeS DUE NOW
83,79.00
RECEIPT
DATEi
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings I
Ducts
Slab Grade S
Return Air
Steel I
Combustion Air
Roof Deck I
Exhaust Fans -
O.K. to Wrap }
F.A.U.
Framing )
Compressor
Insulation I
Vents
Fireplace P.L. ?
Grills
Fireplace T.O. f _
Fans & Controls
Party Wall Insulation i
Condensate Lines
Party Wali Firewall I
Exterior Lath I
Drywall - Int. Lath }
1
•i .
Final
Final }
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs 1
Electric Bond
Footings I
Main Drain
Bond Beam I
Approval to Cover
i
Equipment Location
!
Underground Electric
iI
Underground Pibg. Test
Final €
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines 1
Heater Final
Water Piping f
Plumbing Final
Plumbing Top Out ]
Equipment Enclosure
Shower Pans ]
OX for Finish Plaster
Sewer Lateral
Pool Cover '
Sewer Connection 1
Encapsulation
Gas Piping I
Gas Test }
Appliances ]
I
Final
I
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 I '
Temp. Use of Power ]
Final }
Utility Notice (Perm)
COMMENTS:
C/O,Sr�
J�—�' 07
s�
,f