0012-057 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby aff'ir`m 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
750130 BXel
.,Pate 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'soie_
compensation, will do the work, and -the structure is not intended or offer d for
sale (Sec. 7044, Business & Professionals Code).=' "•
( ) I, as owner of the property, am exclusively contracting with licensed1
contractors to construct the project (Sec. 7044, .Business & Professionals;
Code).
O I am exempt Under Section B&P.C. for this reason
Date Signature of .Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penaltyof 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
prformance of the work for which this permit is issued.
( I have and will maintain workers' compensation insurance, as required by
Sect n 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. CLARMON IAIO& 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,
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
si�pject to the workers' compensation provisions of Section 3700 of th . Labor
Code, Iosh II forthwith comply with those provisions f
�
date: If �C� 0t)ADDlicant
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.anclattorney'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 h
application.
1. Each person upon whose behalf this application is made&each person At V
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.
BUILDING PERMIT PERMIT#
DATE - :. VALUATION LOT'. TRACT
916M.0 0
JOB SITE APN
ADDRESS .13-7,65AVEMDi3RAI%MEZ 774461!014
`OWNER : CONTRACTOR / DESIGNER / ENGINEER
FOUR aEmtills ROUFS, WC. P S I (110H RUCTION INC
SAN 1n3P..1� +lAR.UI140 Qk 92401 RM BUNK)= CA 92423-0°
(d�A3j75z -5833 CM4 1532 .
USE OF PERMIT
SUPPLEMENTAL PERMIT FOR 43 ;L, F. OF Y a" PROPANE TANK
MCLOSURL? - CITY SiT.ANDAND
4 irn ww.I.
43.00 U
EWM.T'.�.t: COST 01r fb:'ivJMMUCTION
P]Mw14'.li'w�7AYg°��
CONSTRUCTION FEE 191 ••000.418.000 $19.00
SUBVI'MAL CONSIMUCHON AND PLAN (MM. $1.9.00
IMS IYRR-PAM FM $0.00
2. Any permit issued as a result of this application becomes null and void if IMAL MAMTFEMS DUE NOW
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. DEC 112000
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- y r
construction, and hereby authorize representatives of this City to enter upon '�'� �� �K��� 1 % �J
the above-mentioned property for inspection purposes: �; 1
RECEIPT DATE E , By // DATE FINALED
is
iqnature (Owner/Agent) 'Date . A
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts q
Forms & Footings
Ducts {
Slab Grade
Return Air
Steel
Combustion Air {
Roof Deck
Exhaust Fans - {
O.K to Wrap
F.A.U. {
Framing
Compressor . I
Insulation
Vents q
Fireplace P.L.
Grills {
Fireplace T.O.
Fans & Controls q
Party Wall Insulation
Condensate Lines q
Party Wall Firewall
p
Exterior Lath
}
Drywall - Int. Lath
{
I
Final q
Final
BLOCKWALL APPROVALS
POOLS - SPAS f
steel {
Set Backs
Electric Bond {
Footings
Main Drain {
Bond Beam,
Approval to Cover {
Equipment Location I
Underground Electric {
Underground Plbg. Test I
Final
Gas Piping {
PLUMBING APPROVALS
Gas Test q
Electric Final I
Waste Lines
Heater Final I
Water Piping
Plumbing Final I
Plumbing Top Out
Equipment Enclosure {
Shower Pans
O.K for Finish Plaster {
Sewer Lateral
Pool Cover {
Sewer Connection
Encapsulation I
Gas Piping
t
Gas Test
i
Appliances
{
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
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
•