0108-158 (BLCK)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 Licen,,e is in full force and effect.
License # Lic. Class Exp. Date
Date'tr Signature of Contractor
ECLARATION
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 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
SeAon 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.
3TATE WIND
(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.,qf Section 3700 of the Labor
Code, I shall forthwith comply Athithose provisiorfs. r-- !
Date: Applicants
Warn i`ig-Failure to^secure Workers' Comp 9666' 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.
Signature (Owner/Agent&3 )"''--1 � j�� Date f t
.:: BUILDING PERMIT
PERMT#•
DATE. VALUATION LOT'
TRACT
JOB SITE
APN
ADDRESS
'
51-420 CWAPALOMA
770-1731-005
OWNER
CONTRACTOR / DESIGNER / EN (NEER
NM
I
WU.1AM L RtM.LUS
DMIAN'0` Z 'LS GA 92210
B2 jio :1 d'.0
CA 92210
(760)116S• 30 •{3
C"? :ft 3907
USE OF PERMIT
MW&M, BUILDING
47 0Y 4' Cr°tR.0 IN WALL -M LF 3' ✓ IARDEGIR �J-A'LL190 LF R' riARD9N
WALVALL CITY 9as^ANDARD
6 FT. WALL
moo IS
:°i FT. WALL
Moo LF
4 F1', WALL
47.41 V
WA .1+ I COST OF twC�N'�° 1�C,�` 01K
y�t�'�QQyy�� Q�,,pp q p � y'�jjj �� p,{glygp
£ .ff:87LS�: 11 RipFLldf3s 94.`.I.'PF+bl�.tlV�RA.
c`OMY'RUCTION FEE 101-000.418^-003 8'�k.RtZ
t.
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AUG 151001
C� OF LA
QUIN7q
NANCE DEPT
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V2,00
TOTAL PTtTWX `EX'S MS.' NOW
s', AYJ
t•
RECEIPT
DATE
BY
DATE INALED
INSPECTOR
gg
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings i
Ducts
Slab Grade I
Return Air
Steel l
Combustion Air
'Roof Deck I
Exhaust Fans
0. K. to Wrap ;
F.A.U.
Framing I
Compressor
Insulation i
Vents
Fireplace P.L. +
Grills
Fireplace T.O. l
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall j
Exterior Lath ;
Drywall - Int. Lath I
1
i
1
Final
Final I
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs- ® ��
Electric Bond
FootingsI
Main Drain
_ C
Bond Beam I ��� C� 7
J
Approval to Cover
I
Equipment Location
f
Underground Electric
Final i ;_l /L��
PLUMBING APPROVALS
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Waste Lines s
Heater Final
Water Piping }
Plumbing Final
Plumbing Top Out }
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral 1
Pool Cover
Sewer Connection i
Encapsulation
Gas Piping I
Gas Test
Appliances }
I
Final
I
i
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS -
Temp. Power Pole
Underground Conduit -
Rough Wiring
Low Voltage Wiring
Fixtures I
Main Service
Sub Panels }
Exterior Receptacles
G.F.I. I
Smoke Detectors
Temp. Use of Power
i
Final i
Utility Notice (Perm)!
COMMENTS: