0102-043 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 0' (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
C211 011C
,Pate Signature of Contractor-
OWNER-BUILDER
ontractor 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 Jo 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 penaity 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.
(AJ)' 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.
OLATH FUND
,-w-
(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 shall forthwith comply with those proyision.
D ,te: r Applicant>' 9
rning: Failure to secure Workers'/ Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless'the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the�above-mentioned property for inspection purposes.
�,S gnature (Owner/Agent)
BUILDING PERMIT PERMIT# I I --
DATE VALUATION LOT 0102-0e* TRACT ~
d J/06/2W 56 :�4B.BiU
JOB SITE APN
ADDRESS
78-523 SAW AURRIO COURr
OWNER I CONTRACTOR/DESIGNER/EN (NEER
78-523 DAWINPAWO COURT 7W75 r"BUCKVIAU-N
LA tdoY'Itt9rA CA, 92233 �e."�xt'.3iM,4ttcD R$UM3 CA' 92216
031—A 2380
USE OF PERMIT
5_%.F. 4% OAf:E:.lE,3 WALI. (R ?."B'1`dKINCJ) r;f: 2J...P. °6H P1I. t ' EWS
OTY S`i'A154k?.i M ONLY
tB M `IJ9`/.iR;I L i, "S
4 F7, WALL a
imi"t"#..I ATi-D con Off' Ci:►m-.,te'ucrn. Oh. 930,0 i
Cb.31+STRIL1,^1111014 FFI1:
4"
no\_10
TEe os 2001
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RECEIPT I DATE I BY.,-' J I DATE FINALED J INSPECTOR
RA
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
1
BUILDING APPROVALS
MECHANICAL APPROVALS
cSet Backs s ".
Underground Ducts
_ _
Forms & Footings
Ducts
_ _ _ _
Slab Grade
Return Air
_ _ _
Steel ; [
Combustion Air
_ _ _
Roof Deck !
Exhaust Fans
O.K. to Wrap i;
F.A.U.
Framing 11
Compressor
Insulation ;'
Vents
Fireplace P.L. (
Grills
Fireplace T.O. !
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath I !
Drywall - Int. Lath1;
I l
-
�i
i
Final
Final
POOLS - SPAS
B{LOCKWALL APPROVALS
Set Backs I : rL,_ (�
Footings 1
steel
Electric Bond
i� c �'
Main Drain
Bond Beam I
Approval to Cover
1 !
Equipment Location
I
Underground Electric
_
EI
Underground Plbg. Test
Final1 i
Gas Piping
P
A'`�ROVALS
Gas Test
,PLUMBING`
Electric Final
Waste Lines I f
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out,
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral ; f
Pool Cover
Sewer Connection;
Encapsulation
Gas Piping f ;.
Gas Test I
Appliances i
�'.
Final
Il
If
COMMENTS:
H
Final 1 i
Utility Notice (Gas;
ELECTRICAL APPROVALS
Temp. Power Pole'
Underground Conduit
-
Rough Wiring '
Low Voltage Wiring
Fixtures
Main Service i t
Sub Panels ,
Exterior Receptacles
G.F.I. I;
Smoke Detectors;!
Temp. Use of Power
a;
I
Final
Utility Notice (Perm)