0205-186 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisionsof
Chapter 9 (commencing with,Section 7000) of Division 3 of the Business and
Professionals Code, and my LicenSe7js in full force'and effect.
License # Lic. Class r Exp. Date
39 r; mc, 1111103
Date Signature of Contractor Av�
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of perjury that I am exempt from the Contractor's.
License,Law for the following reason:
1, 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).,
as'owner of the property, am exclusively contracting• with licensed
"
contractors,110 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 penalty of perjury oneof the following declarations:
I havdland will, , maihtain a -certificate of consent nseni to self -insure, for workers'
compensatid?l ' , as, Provided for by -Section 3700 of the Lab6r_Code, for the
performance of the work for which'this permit is issued.
�(>Z) I have arid 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:
Cartier,,
&�,jA!f 1? eg"D Policy No. 00-164881341
(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 worg7drs' compensation provision; of Section 3700 of; the. Labor
Code, I shalll forthwith comply with those',pr/o'Klisi`ons.
v
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject'an employer to criminal penaltierand civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3,706
of the Labor Code, interest and attorney's fe6s.
IMPORTANT Application is hereby made to the Director of Building and Saf4ty
for a permit subject to - the conditions and' restrictions 'set forth on M
application.
1. Each person upon whose behalf this application -is made & each person it
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void, if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject perm it'.to cancellatioTn�.
l*certify that I have read this application and state that the abdv; information'is','..
correct. I agree -to comply with J City, and State laws rpl - at City
to the building
construction, and hereby autho. a representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
--T q
""PERM T'#'
BUILDING.... MIT"..
`005 W
DATE LOT TRACT
28964
JOB SITEI
ADDRESS.
APN
OWNER.
CONTRACTOR DESIGNER ENGINEER.
PML Q WN fA, I-
WESruafismiqu nwc
7 8.4 W F I'M' AIMAY 111
PAN LAM() CA 921131
LAQUTNTA. CA 92253
(160)771 i"63 QMUV 49772
USE OF PERMIT
SM -.1LOT d? PLAN 31C - P.11,31NIXT DOLIS F10FIX nxe.awc
M1 --t K
WALIAPOOL, SPA OR 6RIVE WAY AAI R4A'kelT
TILACT COVOTRUCTION. i7loo up
:526.00 SF
-D Con 0. C
• ggriAmm )T QNSUROCTION
PFRW.ff-r VAX SUMMARNI:
CONSTRIV 'TION FFM' 101,,-000.418-000 5-0611"
PL". CIFIECK 1011F .101-000439-318
MIECH"IcAl. FRU�` 101,000-4. 1 -000 WIN)
BLEM PLICAL,VIEZ
STROWO MMON M RMSID 101-0DO-2,41000
GRANNO FFR "foi,000-423-000 S 0A
L 1,0PIVUR IMP.&MME AA 4 43. 0 0
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$,I, f, -f, 9. 7 0
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1XISS FRE. -PAM FEW
$0.00
10TAL Plowt 11" 9 31 Ur, NOW
$416319170
20 z
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ff LAQUINT
FINM
By
DATE FINALED
INSPECTV
_2,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
2.
Underground Ducts
Forms & Footings
L
Ducts
Slab Grade
2 _
Return Air.
Steel
Combustion Air
Roof Deck
_ o -
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
��(o -
_
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
_
N Z,
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath -
Final �Z
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
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
0`
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
, �j Z _
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
FinalUtility 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 — 3
Utility Notice (Perm) s -O
COMMENTS: