0301-419 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm Under penalty of perjury that I am licensed under provisions of
H Chapter 8 (commencing with Section 7000) of Division.8 of the Business and
c�i W Professionals Code, and my License is in full force and effect.
G.5 Licenses# Lic. Class Exp. Date
ZO �/ Date _ Signature of Contras , k =
i
V'.�p OWNER -BUILDER DECLARATION
L d I hereby affirm under penalty of perjury that I am exempt from the: Contractor's
Cl) License Law for the following reason:
Z ( ) 1, 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).
M O I am exempt under Section B&P.C. for this reason
N
O a Date_ Signature of Owner --- -
rn
Z WORKER'S COMPENSATION DECLARATION
o a: I hereby affirm .under penalty of perjury one of the following declarations:
Lo F p O 1 have and will maintain a certificate of consent to self -insure for workers'
X W !L compensation, as provided for by, Section 3700 of the Labor Code, for the
m � Q performance of the work for which: this permit is issued.
I have and will maintain workers' compensation insurance, as required by
CCU Q Section 3700. of the Labor Code, for the performance of the work'for which this
&2 rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
IZ Carr '03TATY P1,11IND Policy No.. 229-94x34-2014
00 �• O
g (This<section need not be completed if the permit valuation is for. $100.00 or less).
( ') l Certifythat in the performance of'the workfor 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
3 subject to the workers' compe satlon provisions of Section 3700 of the Labor
Code; I shall forthwith comply wtF�ose pxovsions_� %s
te: Applicant'`{ ,
T'
Y
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties,and civil finesupto $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth. on his
application.
1. Each person:upon whose behalf this application is made & each person at
whose request;and for whose benefit work is performed under or pursuant to
any permit issued'as a result of this applicaton agrees to, & shall, indemnify
&.hold harmless the City of La Quints, its officers,agents and employees.
2. Any permit issued as a resulti of this application, becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of'work for 180:day§ will subject: permit to cancellation.
I certify that I have read this application -and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forinspection pprposes.,r
f
/Signature (Owner/Agent) Date
BUILDING PERMIT- PERMIT
0301-419
DATE I/7�qq yy A�1y� VALUATION j 0 LOT TRACT c,
��}7llAASS .��,,,tto� rrii
JOB SITE.
ADDRESS 52-W p.tE.L C$XF0 DRIVIr
APN
7110-2-99--(h)7
OWNER '
CONTRACTOR / DESIGNER / EN &NEER
CAM �k WANDA 0ARNER
P.0, BOXo']5krx,F
591-800
rRA NC sTO SWEATT TT CA 0206.7
>F+a142A
ao
USE OF PERMIT
86 LI? < :96" S' ALL(CLOUR.TtSY fNSd'Et."t'1t NY4 (.`OL;U.I NIS
PER T'L.AN8 X54 1Y 6' QARDE1, ,I WALL PER CITY RTAVi.}.AR11
614T, WALL 714.00 LY
:i!:umKi m t`C IFf OF C"1CtOM
6.2*01'0 i
:£1Q:i1MFKE t�`Ma"V%ARY
C("►AttpT�tvc:°I°JO�i ��:�: � �� •DGCy^�� $•t,(,��1 3±00.014
JAN 31 2003
CITY OF LA QUINTA
FINANCE DEPT.
ifd:Tt4!'O'r.4- C'014FMT. CTION AM) P A d (xi -W IK
!03.00
'is': Mt1,41AUX 5
i
RECEIPT
DATE /yf y.
BY r---
DATE FINALED
INSP CTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion.Air
Roof Deck
Exhaust Fans
O.K. 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
11 POOLS _ SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to. Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out .,
Equipment Enclosure
Shower Pans
Q.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas �iping
Gas Test
Appliances
Final
COMMENTS:
/ /?`D`✓ti T �2. /� _ t'� �J,3 %2�'.
FrZo�t t�vAG� S s6u
oy(� w(�� r7
r ✓✓ �� —G3
Final
Utility notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Condu(t
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)