0012-080 (BLDG)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
747595:”" MG
B -7 ,s )1 /301/09
Date Z OJ 'Signature of Contractor - -'�
OWNER -BUILDER DECL•'ARATI
I hereby affirm under penalty of perjury that,kam exempt fro 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 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.
(,/!1 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"$100.00or` 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, anagree that if I should become
subject to the workers' compensation provisions, of Section 3700 of the Labor
Code, I shall ortq4ith comply-with1!h sB rof isions.
Date: ��: 1 ,'i~ Applicant
Warning: Failure to secure Work s'�Compensatio�n coverage is unlawful and
shall subject an employer to crimir al,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, purpose .
Signature (Owner7Agent). , � � �� Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0012-M. TRACT
b21`A
JOB SITE
ADDRESS
APN
50.62.5CeALIX PALOMaA,
.7694)("11
OWNER
CONTRACTOR / DESIGNER / ENGINEER
P.D. BOX 1490
P10. BOX 937
1-k Qi7WTA CA 9.22.53
L A. QURgT.f% CA 92253
(760)771-2394 G ave
USE OF PERMIT
.-
SUPPLEMENTAC.PLPUAIT TO '000I JJS9 3110`0r1N0 C HA 102 OF. C:aN'I RACTOR
X�''>+'MIt,TED COST OF CuONS'd`RB7f<."P1[om
00)
Pl�:.'Tdwr nm somm RT
h�II ,1�A1� .UiJS 1571 -000.4423 -OW X4,50
I
SIM -TOTAL CONWROC-A& X.. '
$4.50
[�.9 PRE-PAU> FERE
$0.00
TOTAL TTMM"MS ME NOW
$4 .50
RECEIPT
DATE
1 1 ! :./tib
BY
DATE F ALE
SPECTOR
.C24;;77
.
1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings
Ducts
Slab Grade '
Return Air
Steel 1
Combustion Air
Roof Deck 1
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing 1
Compressor
Insulation i
Vents
Fireplace P.L. i
Grills
Fireplace T.O. i
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath I
Drywall - Int. Lath
I
I
Final
Final 1
POOLS ' SPAS
BLOCKWALL
APPROVALS_
steel
Set Backs i
f -
Electric Bond
Footings i
Main Drain
Bond Beam 1
b
Approval to Cover
Equipment Location
i
Underground Electric
Underground Pibg. Test
FinalItZ
o
Gas Piping
PLUMBING
APPkOVALS
Gas Test
Electric Final
Waste Lines 1.
Heater Final
Water Piping i
Plumbing Final
Plumbing Top Out
-
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral !
Pool Cover
Sewer Connection
Encapsulation
Gas Piping I
Gas Test I
Appliances 1
1
Final
1
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL"APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures 1
Main Service i
Sub Panels 1
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
i
Final
Utility Notice (Perm)