0102-114 (ELEC)LICENSED CONTRACTOR DECLARATION r
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 ffect.
License # Lic. Class (r� Exp. Date
f ; I r�
1 2. 25 0t 10 i ti'F�3fJ, g
'Date Signature of Contractor -
a 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).
( ) I am exempt under Section , B&P.C. for this reason
Date M t 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.
12-01014 INOURANCE W04160443
(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance `of she wor for which this permit is issued,
I shall not employ any person in/an y Inarnner a to become subject to the
workers' compensation laws of Califw`ial an ag a that if I should become
subject to the workers' compengation FprbAvfisio s o Section 3700 of the Labor
,Code, I shall forthwith comply w(th thole on
Date: 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. :P
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 allIt)j and State laws relating to the building
construction, and hereby uthy �yeiresentatives of this City to enter upon
the above-mentioned props; y tor rasp ctron purposes.
Signature (Owner)Agent). Date
BUILDING PERMIT PERMIT#
VALUATION LOT OVY1414 TRACT
DATE.. -- //,
!//
3..•°'Fr.•1 r ".I '. .i�.f�il�,�Jfief�
JOB SITE -Sol
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JWS.
MC CLJC'r.,lLAN EL-YX'!AR!C CO.
LA OYMM& CA 92253
PALM 1Y "MERT CA 92261
(760) 340.8342 C-BUi
5W3
USE OF PERMIT
Iyf7 IC1� 'H t�Lc: x I CK,;:r�l.. i ^A ii i. 6L REPLACE WITH 200 i;lll? SNW'ICZ P-4, 1 9L
'Y A7GdUATIOC'9 1.9
.. : .
FlUr-7R1CA. F3# 101.060"420.0 0
'. FEB 1 S 200:1
Y ul" r D
x
-MrAl. CIti9:111•S`1`MON ANggCjTTP{{��Ir���',Jr�l'�CI�y'ip� I,-
fiOµ12q.50
�.+.�c��rq
• ,. .. I.wSOP 1. y�'.L.•a°':G'.fA3rl:LS.Ci79
� $0.010
'TOTAL PMOUL' ZEB ME.DOW
RECEIPT
DATE fir/ %
By, —
DATE FINALED
INSPECTOR.
a v
,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings J [
Ducts
Slab Grade i f
Return Air
Steel ; {
Combustion Air
Roof Deck i (
Exhaust Fans
O.K. to Wrap I{
F.A.U.
Framing tJ
Compressor
Insulation i {
Vents
Fireplace P.L. I I
Grills
Fire lace'T.O. i {
Fans & Controls
Party Wall insulation
Condensate Lines
Party Wali Firewall j I
Exterior Lath I
Drywall - Int. Lath
11
f.
! 1
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs I!
Electric Bond
Footings I i
Main Drain
Bond Beam ±I
Approval to Cover
i I
Equipment Location
1 i
Underground Electric
i ?
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping I {
Plumbing Final
Plumbing Top Out i
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 i
' I
Final
J {
H
Final I ;
Utility Notice (Gas) J C
ELECTRICAL APPROVALS
Temp. Power Pole i I
Underground Conduit
Rough Wiring I I
Low Voltage Wiring 01*1
Fixtures Ii
Main Service 1 1110,
Sub Panels I i
Exterior Receptacles
G.F.I. I I
Smoke Detectors ; l
Temp. Use of Power
I l
11 .
Final II
Utility Notice (Perm)I
COMMENTS: