0109-090 (BLCK)4 Lj'ftM CENSED -CONTRACTOR DECURAT1614
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I hereby, affirm under penalty}of peryury,that I am�licensed�un,. rovlsions of
Chapter 9,(commencing with Sectiori,7000) of7Dlvisionf3 of,the Business'and
Professionals Code and my License is in full force and effect"� ?,� �if�;*
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.MY License # Lic. Class t ��j4i,1, 'r a°i?. Exp Date ,,
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y•� a-� ._•......,1r ..,..-Yr,i, f�.,._j � �y'3.1�: �_^-••; r.'..H� .o;,.,..
Date r 1 i°Signature of Contractor ! f*
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OWNER -BUILDER DECLAR ATION'+y • ,
;,I hereby affirm under penalty of perjury that I am exempt from,the Contractor's
License Law for the following reason
J
as owner of the property,"amy employees with_wages-as their sole
4r,compensation,-.will do the work; and the structure is not Intended or offered for r
sale (Sec',7044'�Business & Professionals Code) ^;'
�, ,,
R)�,Ias owner of�the�propertytam.excllusively'contracting•with licensed."
`contractors to,construct`th'eqq'project•(Seca 7044; Business &.Professionals
Code).,,i
WO I am exempt under Section r B&P C for this reason
IY yDyate''r}1• }�t� Signature of, Owner
t, r+i* �T t. , WORKERS COMPENSATION DECLARATION` +
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jlihereby,affirmiunder penalty.of;perjuryione of the. oll.. - owing declarations:
' (,)ttI have and will maintain a certficate of consent to self -insure for workers'
yl;compensation ,as;provided for liy Section 3700 of the Labor Code, for the
V. p- 6rformance oflthe work forfwhich this permit is Issued.
F (z )' I have and will maintain workers compensation insurance, as required by
h,Section! 3700 of the,Labor Code,.for the performance of,the work for which this
�permltis Issued',Myrworkers compensation'insurance. carrier & policy no. are:
�m
Caer' '"� j,. ' r tPolicy 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,
�U's�tall
ploy'any' person in any manner, so as to become subject to the
yworkers' compensation laws of California, and agree that if I should become
t subject to the workers compensation provisions of`Section 3700 of the Labor
' ,Code I shall forthwith comply with those'ons "
- "n, �"?>'� Applicant r w s- _�. . _ •.
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g:: Failure to secure Workers Compensation coverage is unllwful and
;shall subject an employer to criminal penalties and civil fines up to $100,000, in
additi6ii 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
!ifor a( permit subject to the conditions and restrictions set forth 'on his
C application
1 °Each person upon whose behalf this application is made & each person at
t whose request and for whose benefit work is performed under or pursuant fo
+ any permit issued as a result of this applicator 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
,j4 permit, or cessation of work for 180 days will subject permit to cancellation.
I certify thatAI havereadthis application and state that the above information is
correct. I'agree to comply with all. -City;. -and State laws relating to the building
,t constiuction;,and hereby autGize�representatives of this City to enter upon
the above mentioned property for inntpectyon purposes�.,�. ,
Signature (Ow„ner/Ag nt).��r`� h f�
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'�Offit PERMIT Tu.z - ii. gjll'1 , r • tp�kt �� . -
BUILDING �PERM��{(.7
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DATE ..,. ✓': 7 .M. ,,, , VALUATION N }, �1, ;yfi {, LOTz: c.'• r D�094 1
JOB SITE{�'fr:`a`,l,� fa;'liT7',A,r1Q'rj:7'r'•,•'i,•,i,.y':�•U,J�/r..�;:2•ZS:.{6+:+Sr'rMR Jiw�'Y{,.:,.;",
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CONTRACTOR/ DESIGNER/ ENGINEER .19 "
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USE OF PERMIT - .'r 's-�S
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110 UP 4' of 10H Blest?f;",X WAU, CITY STA D.ARD ' r + : r er r � rJ � ,• ilw,� :, � „�'I ' � °f
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V-51M,131*AED C081 OF comur-�'. r'Ud°'d
c'EpAb I'RUCTION YZE -00 -418-000 , ,U+`
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SEP 12 2001
CITY OF LA QUINTA '.'•� ,1,,;
FINANCE DEPT.
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UTAL6 S °aJ.�.IY.'SX& ?.' L•fIi• S Lf'•UE PlO . °.%
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RECEIPT
DATE / BY
DATE FINALED ^ t F^
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INSPECTOR . t r'
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE -TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS -
Set Backs I
Underground Ducts
Forms & Footings I
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck 7
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing 1
Compressor
Insulation
Vents
Fireplace P.L. i
Grills
Fireplace T.O. j
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath i
Drywall - Int. Lath
Final
Final
POOLS - SPAS
Z,
6LOCKWALL APPROVALS
Steel
Set Backs 'Electric
Footings%
Bond
Main Drain
Bond BeamApproval
Ti
to Cover
Equipment Location
Underground Electric
Final 6 :.-,5 zr
PLUMBING APPROVALS
Underground PIbg. Test
Gas Piping
Gas Test
Electric Final
Waste Lines i
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
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures I i
Main Service I
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors J
Temp. Use of Power
Final
Utility Notice (Perm)