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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
ate'` Signature of Contractof�
f✓°'.
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
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.
(r I have and will maintain workers' compensation insurance, as required by
Se ion 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.
STAMAND
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subipbt to the workers' compensation provisions of Section X700 of the Labor
XCde, I s all fo hwith comply with thos6$rovisions. '
te;t. ? 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
permit, or cessation of work for 180 days will subject permit to cancellation.
II 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 constrdction, and hereby authorize representatives of this City to enter upon
the
bove-mentioned property fob inspection purposes.
,��
ignature (Owner/AgentDatef
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
04130= $1,2enoo
JOB SITE
APN
ADDRESS 52_141 �'1 A'4%MMIUMMITIMS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
IC%VIRON
DGH .DFYf L011Mis 4 T CORP
152
78-921 RUNAWAY DAY
!A Qi.TMA. (A _022S3
BEM:1.4 UIDADIX& CA 92261
760)360-81306 i7.B i# 9526
USE OF PERMIT
550 L.F. X 6' f,EAkl)FW WALL • 4DRC D S7'.A:i410ARD
ti k!, %hLL $0,410 ;t.V
:9MWXfM3) V:sOS.lc Rf.6• (.r W.t'{E7.1M9JO-r"CI +.i7
1ML+.70100
CONSTiZUt'.TIM FE's 101-000.418.OW $31.00
D a - 0 0 ,
APR 3 0 2001
CITY OF LA OUINTA
FINANCE DEPT
90B. 3Y1AL Cat' :W,! I°t UC°'i`ION ACID ,P: T -1W C;.fiWK
$:31.00 � .
LEMS FRE -PA 61,RES
$0.0910
WEAL rM?M ITFUS 13 UE A OW
$31,00
RECEIPT
DATE
B11 /,'
DA E NAL
INSPECTOR
1,
<<
f1.
INSPECTION RECORD
OPERATION DATE "' INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap `
Framing
Insulation
Fireplace P.L. _
Fireplace T.O.
Party Wall Insulation
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts.,,
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
I I
— POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
f,'/� �� [
Electric Bond
Footings
Bond Beam
_I
%`D l
Main Drain
Approval to Cover _
Equipment Location
Underground Electric
57
'!l?.trlD
Underground Pibg. Test
Final
/
Gas Piping
PLUMBING I�iPPROVALS
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
Final -
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underqround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice