0010-032 (RR)U)
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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 Blind eff ct.
License # Lic. Class i ' Exp. Date.,,
VD
� '�RAV) Signature of Contracto, a -'� ►' " !
v / 1
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.
V.1 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:
Carver Policy No.
LEMON MOURANCE 1
(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 fo5.Xhi% this permit is issued,
I shall not employ any person in any mane; so s t, become subject to the
workers' compensation laws of Californi��aa and grey that if I should become
subject to the workers' compensatign i�yfvision of ecrion'3700 of the Labor
Code I �h lj f with comply witp p,ose prcl i on
°G- �J^
Dater .f /} Applicant /ti...,Z:.
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 pursua%t• to
any permit issued as a result of this applicaton agrees to, & shall; indemnify o
& 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 stat that the above information is
correct. I agree to comply withjallrys;4ty, anSt/ate laws relating to the building
construction, and hereby auth?ji a �epre e`ntati es of this City to enter upon
the above-mentioned pro�e 4r inspec I - n �urposes.
/Signature (Owner/Agent) ~"' -'" Date/ /v
V17.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
'�13t�tfSt � �"iiil�J6l
JOB SITE
APN
ADDRESS
49.675 COAC IMXA.D1�3: M
-
OWNER
CONTRACTOR / DESIGNER / EN INEEA
FRAN KOZAAL.
RC?OP bUls ffPF(`1Wry
49.675 CSF AMLIA
74 075 ATM 1A
I AC9XNTA CA 9.2253
PALM DUM i CA 9 211
(760)341-6073 MIA 14.20
3
USE OF PERMIT
C ENEMePaL' BUDDING
R&92.t7O1p WITH CONCRETE TY1.2 (C3,AS3 JV)
eil'e',1x.00ir ,'7 1X
CIDSlT CSP" G"i33.Y�'�'�,I:7'4''110JR
81700.W
y�},y�'' p �giy�y�'y�f ryq^y (� �1j ,p'�B"TJ1D
"Q1.WF Tf89 1 a 1 �Uob:a4 3 €'-000
E4.
&1'1'.1 1-'i'MAL CO1MMU ,ON AND PLAN CIIt—T.
X30.00
jF LR,W PRE -P.1' FERS
$0,00
110TAL DUE MAV
.�
OCT 04 2000
X" di LA47
RECEIPT
DATE
�a
BY
D F AL
INSP CTOR
Ulu
/
INSPECTION
RECORD
I
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
' BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs-
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel _ r
Roof Deck //_/ �� :r�PZ� :
O.K. to Wrap �j
Combustion Air !
Exhaust Fans (:
F.A.U. F
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls I
Party Wali Insulation
Condensate Linesi
Party Wall Firewall
i
Exterior Lath
}.
Drywall - Int. Lath
1
Final/�j�� �-
BLOCKWALL Ar PROVALS
Final t
1 POOLS - SPAS
steel
Set Backs
Electric Bond I
Footings
Main Drain I
Bond Beam
Approval to Cover,
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping !
PLUMBING APPROVALS
Gas Test
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 I
Sewer Connection
Encapsulation I
Gas Piping
Gas Test
j
Appliances
Final
COMMENTS:
1
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.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)