0105-031 (MISC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HI Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
fV W Professionals Code, and my License is in full force and effect `• ..
ri =) License # Lic. Class Exp. Date
791225 .B - -',\k
7 1 /
Date Signature of Contractor '' / /
d
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).-"
O I am exempt under Section , B&P.C. for`ihis 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-
( ) 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.
(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 Sectiun 3700 of the Labor
Code, I shall forthwith comply with those provisions. A
Date:..--Applicant—
Warning:
pplicant Warning: Failure to secure. Workers' Compensation coverage s unl'' wful and
shall subject an employer to criminal penalt •3s and. civil fines up to $1%,000, in
addition to the cost of compensation, damagesas provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his• -
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection puIrposes.
Signature (Owner/Agent) -04Date
BUILDING PERMI` PERMIT#
DATE f VALUATION (LOT 010.13- 31. TRACT
JOB SITE � � :JAPN
ADDRESS
78 -MID SAGUARO DRIVE
OWNER
CONTRACTOR / DESIGNER / EN INFER
yy ��y��.���yy TTppy��yy��yr
R.a�c:4J14ARD LAM
Yy xx,,/� S�ppAp y1yy��y�i LAM tr
Y.�9:'.h.`dVd"N'�:1..7 J.atTM
R6, BOX 450
111 C UKIL`?? A 0RCU,
1; A.QTJWTA CP, 92253
PALM MI.Wer CA 9ZZ60
(760)340-"82 CSV$ 6 426
USE OF PERMIT
MISCE U.0490us
SCJP'I';k:13MEY' A], TO P';~tt?t@ T 0102-a86
CFL4NOR OF CONTRACTOR
N6TLV=KD COST OF CONSTRUC19110DI
11k113J'1,EAdWAL FEMJT FPC 101-000-423-000 34.50
y�
WSUB-TOTAL. Ci. 'k . LUC` 10.1`4 AND PJAM M c`..�1�.� CK
$4.50
--�. L.T'r;3S PRE -PAID PM3
JiPM?NTFMD1TZkT0W
$4.00
T4 S)
CITY OF LA OuINTA I
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade 1
Return Air
Steel i
Combustion Air
Roof Deck 1
Exhaust Fans
O.K. to Wrap i
F.A.U.
Framing
Compressor
Insulation i
Vents
Fireplace P.L.
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation 1
Condensate Lines
Party Wall Firewall
Exterior Lath ]
Drywall - Int. Lath
Final
Final I
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs i
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas
sTesElectric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances 1
'
Final
1
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 Poweri
i
Final f
Utility Notice (Perm)
COMMENTS:
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