0108-232 (BLCK)LICENSED CONTRACTOR DECLARATION
-I.hereby affirm under penalty of perjury that I am licensed under, provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
I Od31st.11
Date- ,y Signature of Contractor
"—'_ 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 intend 3d 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.
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 ITM R COME' HIS M, 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 t�e workers' compensatio_ rovisions of Section 3700 of the Labor
,.._Iio
Code,
�com I with t �e�osn
Date: ADDliant , s0
M
f
._
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 chis
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 foinspe Ion purposes. :
Signaturer(.Owner/Agent) . - 1,_ Date
t °
r. "BUILDING PERMIT' PERMIT ti
DATE (,r f ro VALUATION LOT �-• TRACT
eF f • 1.r 1 � � � -.
JOB SITE -'� APN
ADDRESS
V- SAGVAR0
IOWNER
77 A -564-A. C:`O'i.3Mlf Y MOB I'M 0.3 i 3
FA1..CItI DEW= CA 92211
I USE OF PERMIT
CONTRACTOR/DESIGNER/ENGINEER
? t Dir I TRT QA 92211
(760)4088 3495 MR 6133
GDWRAIL
130 1,F 6' ItAX)bg4 WALL &.700 1,,F S' OA.ttl:)MN •W -LU S>: TH CITY
5 Per. WAI.P..
I.M. ita I'3?
X06 LE'
ESTMADW C0137 010 COMORUMON
FRfi. '.iT.I4'TXffubtf1 Wy
MSTRUMON M, 103.000 418-000 S112100
?SlA",i3-•ICTi'Y`AL CaC)N'SIRUMiC1N AND PIJAR C H9M
LESS PRE-PAIDFMi",
rug -MI, F!=8 AwE,wow
II AUG 2 3 2001 L
CITY OF LA QUINTA .
RECEIPT BY DATE FINALED INSPECTOR
A
INSPECTION, RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings !
Ducts
Slab Grade j
Return Air
Steel }
Combustion Air
Roof Deck i
Exhaust Fans
O.K. to Wrap ]
F.A.U.
Framing i
Compressor
Insulation i
Vents
Fireplace P.L. (
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall f
Exterior Lath
Drywall = Int: Lath ! _
-
1
1
f
Final
Final i
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs 1 �-,��-t7j S�
Electric Bond
Footings I _
S7
Main Drain
Bond Beam 1 9Q t
Approval to Cover
i ` G
Equipment Location
1
Underground Electric
I _
Final ! �J` 3 S'�
Underground Plbg. Test
Gas Piping
PLUMBING APrROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping ;
Plumbing Final
Plumbing Top Out ►
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral i
Pool Cover
Sewer Connection i
Encapsulation
Gas Piping ]
Gas Test I
Appliances I
1
Final
I
COMMENTS:
Final
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit
Rough Wiring a
Low Voltage Wiring
Fixtures
Main Service }
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors I
Temp. Use of Power
i
i
Final I
Utility Notice (Perm)