0306-401 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class I Exp. Date
r O LO 64;193: 6f30.,'03
LU,
oZ r ✓Date + �~ ' Signature of Contra6tor ��""�•--
Co 0 ° 1L_
J U 0 OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
C'') () I am exempt under Section , B&P.C. for this reason
LO
0 N Date Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
p2
Z I hereby affirm under penalty of perjury one of the following declarations`=
r O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
0U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il U')
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier :1.�e`T')ONA], UNION k� Policy No. ?t�$:itty
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(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 as1to become subject to the
workers' compensation laws of California, and a fee that if I should become
3 subject to the workers' compensati n-provisions,of Section 3700 of the Labor
Co, I shall forthwith comply"ith,those provisions.
✓Date: f f'"`> Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and;State laws relating to the building
construction, and hereby authorize,representatives of this City to enter upon
the above-mehoned»prope rty for injg pection.purposes.
Signal • re�(O ner/Ago`n. A3, �'"�1(- Date
BUILDING PERMIT PERMIT0#*-401
DATE VALUATION 81AW,00 LOT 143 TRACT
JOB ADDRESS �i-7lriPxr0ll:+iFi�i�t
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
SIM$ <z'ic:;t:` R3 _F0P M r VE ADT VIV
S_ EZA H014,K-S
'LA C;jiY7T+1n, OA 92253
1IRM tA.T:: C A 92883
(BCta}FJ33�39J�i ::`"f::•L�� fi�:iE�
USE OF PERMIT
aal TIMAT., B UKDA46
b Fr. 7J AIJAI.� 00 IX
FI'I TMA T;E D COST OF CO,"1�r� TKIIJIMN
I
CONS RUC:'.P`1024 :'Mzw 101•DOD-418.00 i X51. to
LEM ME -PAID 17M,
9},00
OITA. L < TL1xA/M.d 8" I. S DUE NOW
' JUL 012""3 +
RECEIPT
DATE—, r
BY l -
DATE F AL
INSPE T,Oij
31 o -I
,�'
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
OX 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
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Bond Beam
Main Drain _
Approval to Cover
-
Equipment Location
'
Underground Electric
Underground Plbg. Test
Final / 3i
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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) .
COMMENTS: