0104-310 (AR)--
JOB SITE
� W, -f
.-7141 In
OWNER'T.". CONTRACTOR DESIGNER ENGINEER 70',
W W, I h6ireby. af�ir�n under penalty, perjyry tl�at I am exempt f rom the Cc -s'-,
LZ as owner property, or my employees'with wages as the
owner.o A 'e", property', f'am, e'xc`lusivel� contri6ting -with* licensed
I am _exe�t 'under Section B&P.C. forthisreason SUPPIA, ENTAL PEIRMIT FOR.IWDITIONA.L LIVFNG SPACE OF 33 SQVIV-1
WID171R, CONSTRUCTION (000?- 1
4 WORKER'S COMPENSATION DECLARATION -
under,penalty of
nit I
vi�ancl Vqill ifi'aintiiin_ Wcertificate of consent to' self -insure for workers'
abor Code, for the
�'performance of the work for which this l5eirmit is issued.
1 Wav-e-i-a- n -d 611 "�iahain workers' compensation insurance, as required by
,Sibction 3700 of,the Laboi� Code,'jor the performance of,the work for which this
Policy No:
is secti ed �ofbe completed if the permit valuation is for $100.00 or less).
erformance of the work for which this permit is issued,
I'shall not em'plo'y' an'y' person in any' manner so as to become subject to the COUSTRUCTION FEE -000
10 1 -000-41 118
w6r�ers' compe�sation laws of California, and agree that if I should become E J117CIrRICAL PEI 9 10 1 -ON-no"'m $1 L2i,
s b ect to the workers' conipensation provisions of Section 3700 of the Labor Xrwoa WrIaN VX9 101-000-241-000 % 50,:
Code, I shall forthwith comply with those provisions
Warning: Failure to Secure Workers' Compensation coverage is unlawful and
k�ll ' ubject' n 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
I Wof the Labor Code, interest and attorney's fees.
�'IMPORtAINIT Application is hereby made to.the Director of Building and Safety
'�for. a' permit subject to the conditions and restrictions set forth on his
1 � Each person upon whose behalf this application is made & each person at
A.
whose request and for whose benefit work is performed under or pursuant to T(THOW AMD PIAN M, WK'.- .
any permit issued as a result of this applicaton agrees to, & shall, indemnify LESIS PFM,-FAYD .66
s 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 2001 1 'ERMIT MMS DUE'YNOW
M AY
permit, or cessation of work for 180 days will subject permit to canc6llation.
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 CITY OF LA QUINTA
construction, and,hereby authorize representatives of this City to enter upon FINANCE DEPT
the above-mentioned property for inspection purposes.
RECEIPT DATE BY DATE FINALED . INSPECTOR
Si
INSPECTION RECORD
_ OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
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 Walt Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice (Perm)
COMMENTS: