0104-311 (AR)•LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions'of
Chapter 9 (commencing with Section 7000) of Division 3 of the' Business and
,= rofessionals Code, and my License is in full force and effect. ' f%
License # Lic. Class Exp. Date
714188 , � � 1.Cle'31Mi
Date < Si nature r
of Contactor ";' .;
-,,j, /.,,,;e f 9 .
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 Sianature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
�(YJ 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.
( ) 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.
�Ra;'3l I)IR F 13.�s.�`.HAP TOO. "'C -MM -09
(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 workers' compensation provisions of Section 3700 of the Labor
Code, I s 1 forthwith comply with those provisions.
Date: ..,--,//. .�. Applicant :
Warning: Failul'e 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.
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.
i
Signature (Owner/Agent) ' !' : gar J Date "
BUILDING 'PERMIT PERMIT"
•
DATE ! VALUATION + LOT 6iJiDQ4 ^3. TRACT'
.�
FIs.' r Zrws19�
JOB SITE
ADDRESS•
APN q�<
t'
f49-2,79 PARRO x�
-4aI
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i1DT.''0RY t R ,Y`KHL .. CGIAWAMIES
C-EWMRY CROW&L Ct"iMWt:f33 MI -i's
1.535 so, V W9.11 11*1 S't7•? -4200
1 a 3 5 So. "L)" 9'1'it �i.'1 "J% al"m #2,00 , , . .
M&d aMWAR D'iKO CA 92A N
SAN B'ETZKARD I1^ O CA 92.408
(909).381.6007 CB1X 2120
T
USE OF PERMIT
SUPPIEMEI3',j`AI, P10AIT FOR. r" m8.3f:&ITICS•t)f.AL :LJVr iQ SPACE OF 33 .Qn
DON LIS ROOM SI?
ES'T`MAT (1101W OF C(g19 STRUC1100
FMAIrr FE'S; ATIi/T. AIRY
PLIAN CHRCK FEE 101-000-439-318
C014S`fiIi.11trTIO14 FEE 101,,000-418-000 �zJ.Gf3,
F.LF,..CTRICAL FEE 101.000-X420-000
STRONG MOT ION1 FEZ- R SM 101-000-2#11-000
D Awlv cow 'cMON Ate', PLAW CHFX. e
$59.90
' D.
LESS PRE -PAID FF2..M
W
MAY 1 1 2001°1-0 _: MMT n.-m-DVEnow
CITY OF LA OUINTA
FINANCE DEPT
M
RECEIPT
DATE !
BYq
DATE FINALED
INSPECTOR t r
A
# 'INSPECTION RECORD
. a
—i OPERATION DATE INSPECTOR
BUILDING APPROVALS'
Set Backs i
Forms & Footings ;
Slab Grade I
Steel ;
Roof Deck 3
O.K. to Wrap i
Framing ]
Insulation 1
Fireplace P.L. I
Fireplace T.O. I
Party Wail Insulation
Party Wall Firewall
Exterior Lath I
Drywall - Int. Lath I
I
]
Final 2
BLOCKWALL APPROVALS
Set Backs I
Footings
Bond Beam
Final ; I
PLUMBING APPROVALS
Waste Lines
Water Piping 1
Plumbing Top Outi
Shower Pans t•
Sewer Lateral
Sewer Connection I'
Gas Piping i
Gas Test 1
Appliances ]
1
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole'
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures i
Main Service )
Sub Panels ]
Exterior Receptacles
G.F.I. )
Smoke Detectors J
Temp. Use of Power
i
] i
Final {
Utility Notice (Perm)
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Cnnn D !`..n1.i.le.
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Final
COMMENTS:
POOLS - SPAS