9702-032 (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,,anclmy License is in full force and effect.
License #' Lic. Class Exp. Date i .'
/ate - Signature of Contractor—
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors
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.
(. ) 1 have and will maintain workers' compensation insurance; as required by
S ction 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.ojqe Fjal) Policy No. o004,7
(This section need not be completed if the permit valuationisfor $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 agreeithat if .1 should become
subject to the workers' compensationprovisions of ection 3700 of the -Labor
C • c7e, I shall forthwith comply with those provisions:
Cod
"3.. bt.•e:;-7 Applicant C u i44.,''t,
Warning: Failure to secure Workers' GompensaUOn coverage Is ual ulfand'.
shall subject an employer to criminaKpenaltWs 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 f
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
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 prurposes.. , =
ignature (Owner/Agent) - .,,Date � /,4."6
BUILDINGPERMIT PERMITN CONTROL#
4 712
DATE 2»a/97 VALUATION $1,234.0.5 LOT TRACT_
JOB SITE
ADDRESS 54-540 AV NIDA Ri' MIM RFZ
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
INIMI.L V3:NT(IEtES
;y 4'f3RI.. NG I40NI S
Or P.O. BOX 450
P.O. BOX 450
[,A QUIN'1:A. CA 92.253
GA C1tI13 7A CA 9225:3
C.BL#
USE OF PERMIT
57.51 r 5 C4tiRf.1 N i3y OCK WA11,
5 FT. WALL, 57,00 LF
1,S g IaoTEO COST 01 CONS R UMIGN
Mhlff FE11-i:SiIJ(L9J.VAARY
C0 8T42.UCTIt_tN F V3 F 101-000-418-011V
PAIDA.1. C0N$"rRU(7T1(_)N SND P ,AN CIMC K
$31,00
L,FSS PRE -RAID FEES
$0.00
FEB 14 1997 TOTA4,.PV RMIT ai°CES DUY, NOW
$31.414)
CITY OF LA QUINTA
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final:
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs loe
Electric Bond
Footings 6 "
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)