0202-214 (SFD)LICENSED CONTRACTOR DECLARATION
-
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Sectiop.7.000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
-dz, Signature of.Contractorz
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.
d, I have and will maintain workers' compensation insurance, as required by
Non 3700 of the Labor Code, for the. performance of the work for which this
it is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
E4TXfE f UN 00J I�$S1� Ql
(This section need not be completed if the permit valuation is for $100.00 or less).
(t) I certify that in the performance ofthe work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become"'111,_
subject to the workers' compensation provisions of Section 3700 of the Labo!•
:`Code, I shall forthwith comply with tho$'e'prbyi ions. s.
Date: ? 2 7'-a1 Applicant .4791
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
fora permit 'subject to the conditions and restrictions set forth, on -,his
application.; n
1. Each person upon whose behalf this application is made & each person at y,
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',, indemhify r"
& hold harmless the City of La Quinta, its officers, agents and employees:t'
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 tds'Cancellation
I certify that I have read this application and state that the aboveflnformation 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.
c -eras f.
'Signature (Owner/Agent)Date' h
(r _
BUILDING PERMIT PERM T#
DATE VALUATION LOT TRACT
si r/ -y '7 (..'— , iln191' e.'U&N '73 28964
JOB SITE
APN
ADDRESS
.4,11X475 RUTCH.0 1A M M.03)
: 649-100-015,
OWNER
CONTRACTOR/ DESIGNER /I EN INEER �.,
PIAXJI� QtIT.riaT& X=
M"V WMOT HOUSING 114
;5.9681n. 'r.I'1'R EII, K71 E $ 02
7U-401 FMOTMAY 11:,1
a'3A1eJ 1SMMI CA 92131
Lf,, Qt17NrA CA. !M251
(760P71_3363 CBlif
USE OF PERMIT
SPOOL FAQV_ VWTa W0
SYD n LOT 74 Pl'.,A N IBP- PEMMIT I9r;;.-n-V T INC .,Ullr, BLOCK /
WALLA P204 SPA Oil DR.i`tii'F' WAY' APPROACH '
TRACT CONST1ttlt.TI 14 SP
PC3FiMPA` IO 526.00 SJ
CCAISTRLIC:T3fJN F17.2; 101-000.41€-000 1961,511
PLAN CHECK F<eE 101-000.439=31$ $7i►' IX
WCHANICM, FSE 101 ••000-121-DOO $02,50
II Lilt' RICAL 17&; 701-000-42" 00 $15'7.431
I'1.,timblAo PLY, 101.000.419.000 $194.25
VRONO MOTION IrEF, r RESID 101-000-241-•000 $19,19
ORiWHO "% 101-000-423-000 $20.00
-
0B/F10PER I:MPA,Cr F&' al,9fdR00
� s � r<. 'i h r� i!q'r �-y �A�p •., 5 n ll .,. - .. ].• ��d+:6fiYr
FEB, ` 7 2002 1 �
k'9p 4,6, 70
a-, / ...
:. .•<
nn i�p_ ggppp��... •
`
RECEIPT /mss
DATE '
BY �
DATE FINALED
INSPECTO
`•
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ _
Underground Ducts
Ducts
Slab Grade
- 0
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
�_ Z
Final �2 — —
BLOCKWALL APPROVALS
steel
POOLS - SPAS "
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Top Out
�' �� -
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
�- _
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
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: