0109-183 (COMB)LIC CONTRACTOR DECLARATION
I hereby affirm and qty of perjury that I am licensed under provisions o
Chapter 9 (commen Section 7000) of Division 3.of the Business an
Professionals Code, _icense is in full force and effect.
License # Lia Clas§ - s Exp. Date
0,5.,4 iac
Ufa
Date' �-?"�P Sig nature of Contractor b" ! `� �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
contractor's 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.
C)- I have and will maintain workers' compensation insurance, as required by
ction 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 ,S1'..AT COMP1101SA'1':f Policy No. 00406163
(This section Geed 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 3790 of the Labor
Code, I shall forthwith comply with thosepro isions.
-�
Date: 60 APPlicant / /. ✓
Warning: Failure to secure Workers' Compensation,
is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety -
for a permit subject to the conditions and restrictions set forth oh his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance. of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property or1 inspection purposes -
.f
Signature (Owner/Agent) _M �A�j �' Date
a,
BUILDING` PERMIT
VALUATION LOT
JOB SITE
ADDRESS '%&.2,,24 SAN
OWNER
WOO1:i:C;:P 1D B41,8 . 0A
PERMIT #
TRAC
APN
CONTRACTOR/DESIGNER/
M
IN
64 PALM DESEIRIT, CA 922( 50
(760):340.9000" CM6, 35 C
USE OF PERMIT
! �` Iiii.F� PAA_ VQfX1 V.r?JR'.0C1C f:fiiil' I.0 J�1�d'.�i.`d'F'.i'ia`iAa1 L P I P, �3'I'3;$Y�! 1�,C3.
1' ,01"HUI T.N0 C" -AV, ULKY1014,8112 V 4' LULOCK U111MEN? :
V34CLOSURF,'At"I Y u'C,r1;td1"aARD
+ On)
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irl � 12.00 LF OCT 18 2001
f1
MAIN t 1.111ROK PI'd 1 til M0439-318
fUd0V-8'FJ%:HICA1,?.i .f, 1€11-000.421-00 .
301.000-420-000
Pw:U.M 9E1+i0F2Z-- PO -Cal, 101-000.419-000
i'.ON;i'!'11,1a'Gt`1:ICM FRE 101-000-418-000
R % •'1fJ`[ T.,C'��I3 3:iT 3.E:�7�T. fiIL� I: LW CRECK
1VjrAL,*PKVMTFKES DUE NOW '
IPT DATEI. BY DATUi INA�L7ED
.A OUIN TN
'6 OEC
INSPECTION RECORD.
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings ����. 02�
/
Ducts
Slab Grade �yT„yam,y /
Return Air
!
Combustion Air
f Deck
Exhaust Fans
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Footings 3.�-
Electric Bond
Main Drain
,� 3
1_
and Beam - - Z
Approval to Cover
j;�j/7e�
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
- 2,.-Z_
PLUMBING APPROVALS
Gas Test_
?_ nZ
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
_ v
Gas Piping
_s Z
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) g _ , -
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
.jvI.
-3
a Detectors
Temp. Use of Power
i
Final
Utility Notice (Perm)