0106-275 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter P. (commencing with Section 7000) of Division 3 of the Business and
C14 W Pfofes,)Als Code, and my License is in full force and effect.
5 C) cerise # Lic. Class Exp. Date
CYLLI
r
ZO d�D to Signature of Contractor '`� ' ;�„"� r� _M _
J U OWNER -BUILDER D CL`ARATIO.,,,,, '
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole
compensation, wil(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).
C0 () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
Q)
IL Z WORKER'S COMPENSATION DECLARATION
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q () ( ) I have and will maintain workers' compensation insurance, as required by
OLO Q Section 3700 of the Labor Code, for the performance of the work for which this
0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
1�t Z Carrier Policy No.
ob r=-x..v STAIR kfOWD
J(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code,,J,shall.fort with comply wlt(%those
provisions.--..
Date:,r ✓ 7 " Z Applicant
Warning: Failure to secure Workers"Compensation.coverags unlawful and
shall subject an employer to criminal penalties -and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
' correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives, of this City to enter upon
the above-mentioned property foer inspectionp/urposes.
igftatu a (Owner/Agent) " x " Date",
" BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT `
VIC9f3$i,1"it$
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
3400 C.Ft4YTRAL AV1:•:NW ZITE 315
81:65 MtJiTMMA; iii,"h' ATE
11T.W1;> R CA 925r,;ti
1:AQUit3TA CA 02M
USE OF PERMIT
:rte^r�]✓ w��'�1� ��.�
FEW:J.1:�l PA. AL AP-MISI£6.t"ii2'&I:iERS skIALL i39 rN F':i.AtCLAT i'R&PLASTRR
zea i : 10ta, P001a i+QUIPMENT MCs �5,UR NOT IrrC�,f3ra�.a�.
POOL AMOK UPA 11,080.0014
VIVIIA t 1 C04IT''r C)F CS?N"•0'I.'ks'OMC3N
:s!.%,S100JX-)
TM MINIA"
Pi..AAi amrwc Yin 101.000x4 X9_31 b 893,�f3
COkxg1"Rt3v9'ION FEi, 101-000-418-000 $1,44.60
MECHANICAL FEE -P001, 101-000.421.000 524.010
21r fCTl.ff.A.t, rep., Mvtjm 101-000-420-000"'- V5,00
t
F'T,.UM11ma few"? P0011 101.0i? -• . , ; .�»
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JUN 2 2 2001
CITY OF LA DUINTA
FINANCE DEPT
KW-TC,XrAX,C0A1a'".' ,. , 11fi
UM PRS -FAM M
$0.00
TomAL 1?1MA,Ftu Dug I'Tows
330)
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
t�r1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
14
Se Backs
MECHANICAL APPROVALS
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
'
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
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
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
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)
COMMENTS:
No
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Y
`till
SF
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,. --4 A- . E -INSPECTION --FEE 0 '
.a
L BE CHARGED IF THE APPR
C I T OF LA QUI TA NS AND 106 CARD ARE NO N
j BUIL ING &SAFETY EPT.
T E SITE FOR A SCHEDU .ED
APPROVEI PECTION.
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NO EXCEPTIONS!
FOA CONSTRUCT _.- --
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