0202-223 (SFD)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
70109 13 WC
A'
/Date Z-'° p O Z Signature of Contractor
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'.;r
.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
Codej.
() I am exempt under Section B&P.C. for this reason
Date Signaiure 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.
' (er I 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:
Carrier , Policy No.
'STATE AY146 �ui8^1Sg8�i3•�P
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 1'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' ompensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with t ospAr Tovisions. -
Date: ,7_.774ZZ 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.Y
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. a
IMPORTANT ,Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on,hi's
application. ,
_A. 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
an=t 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 purposes.
xSignature (Owner/Agent) Date
a
BUILDING PERMIT PERMT#
DATE / VALUATION LOTTRACT
c7. % 4C 2,R4&
JOB SITE - `
APN
ADDRESS
4"2-5.R4.NC- LAS MARWOSAX
OWNER
CONTRACTOR/DESIGNER/EN INEER
PM LA QxF1l14TA„
'I-W3'S W'. °:A3OU MG DTC
9�1968I�apB r?' S:1,'0 1r, UUITE
`�i8.40l it4'RTHOTIV� AY 111
�1r02
- %;A\[9 �'5h�•C'K) �. CA .92131
/vA �♦y (,
.1A l�U24 d L�a1. .. �. A z'G�e_) Jr
j (7610yi 1.3363, C91R. 49?2
USE OF PERMIT '
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5010 a l.O d1k PLAT . SR: �,t'+�1lWY'7 MURS 4CIT IMCCUDZ i.%,1•W.I X ♦ ' .
' 'A1W, P001t SPA OR )^sR111E WAY .,OPi;OACH. 75% PLAN G."1:ECK FFIF,
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RY
CONISI 'Rt CIHON TEE 101.000.418,000 $1,038m
P AW C,F ECK rK9 101-,000.439-319 $211.07
CHA10CtALIFEE 101.00042.1i-000 8f)�u♦
E1.W7,`RICAL F1W101 dh�Q-� ;1»ttilU s 1. Y
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STRONG MOTION FEI.SR df3 10) -000441-000
� RAMHO ME, '101-00 13.000 MIN
YMMOP01.IMPACT FE'W �_►,x+ 7.0#1
A1:'1' 1N .P1r13UC PLAC)~S - RKSIr 10-0100-4454M SA 18,
+ffi
I`i°M'TI. CfiNh'U'`?�iA5 P£;K9 CHECK
LESS nmpfw I-Im
$0.00
P.C.o-�IIY'��.1'M3 ,11'rS.k9 s TANNOWFE6 2.7 2002
4 . ,• t�3g .7'Vo-1i"o
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RECEIPT:
DATE I
BY ,-,,-•'
DATE FINALED
INSPECTOR,
,�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_ 9
Underground Ducts
Forms & Footings
'fi
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
— — V .. C ,I
Exhaust Fans
O.K to Wrap
Framing
_
�- �,
A.U.
Compressor
Insulation
- G
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 -- — y _
C/
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
�j _
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
-
A
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final ; d�
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) . . p
COMMENTS: