0109-236 (BLCK)r
H
CV U)
W
Ouch
' W
oZ�
co 0
JU CD
C:) OWNER -BUILDER DECLARATION
Hd I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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
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:
Carver 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
subject to 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 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
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
"t 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
t;onstruction, and hereby authorizer presentatives of this City to enter upon
t•�e above-mentioned property rf�%O'Mspectio purposes.
COT
ignature. (Owner/Ageht) ter^" Date d
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 ' DATE
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
JOB SITE
ADDRESS
780880f�.�ftc fAr 0102
Date Sianature of Contractor OWNER
BUILDING PERMIT
VALUATION f LOT
76.4 5 F3IGHMAY 1 11, ULUTI • C
L..A.QUINITA CIS 92253.
USE OF PERMIT
PERMIT N., .• .• •Y+ � j'`
4.,
9�- TRACT y
14
APN
CONTRACTOR/DESIGNER/EN INEER '
I..h `IX C'A (,10 ..'RllM014, RIC.
C. '
78`435 d1d0d3WCA71 111, WlTEE C
L.A. QuLgT.A. CA 92253
(7r0)SC•4-322+5 T"m 5902
20 1, F 4' f2'StUI?ANZ INCIZIStIRE PER. CITY STA34DARD
20,00 IX
EMAIXIED COST OF, CON91MAMON
POMW F2X SUMMARY
C-040` RU(`!,' 014 TIM 101-000-418-000
11 ra o
SEP 2 7 2001
CITY OF LA QUINTA
__FINANCE DEPT.
ffUB-7.'OTAL CON19 F UC TH-) t' AIQ'J�J��pp'L�� LWOM �}L�
y J1lMYJiA �RR•-A"l3(IJ K'.,Ci�SA3
RECEIPTI
DATE � /! i BY DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
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
BLOCKWALL APPROVALS
POOLS - SPAS j
Steel
Set Backs
Electric Bond j
Footings
Main Drain {
Bond Beam r
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test {
Final.
Gas Piping {
PLUMBING APPROVALS
Gas Test t
Electric Final . [
Waste Lines
Heater Final
Water Piping
Plumbin Final I
Plumbing Top Out
Equipment Enclosure I
Shower Pans
O.K. for Finish Plaster I
Sewer Lateral
Pool Cover I
Sewer Connection
Encapsulation I
Gas Piping
I
Gas Test
I
Appliances
I
Final {
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:
c�osEo -
%S'T
(((