0011-004 (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 License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor- — —
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
(t✓ 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 /n !� r,, Signature of Owner `,, A
V0,� 3
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
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 $100.00 or less).
(,) I c'e'rtify 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 of Section 3700 of the Labor
Code, I shall forthwith comply withthose provisions.
Date: f t s _:r a ApplicantrN.r?�.:»�,:
Warning: Failure to secure Workers' Compensation 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) r�"•f4.. �' �r - Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
45-6M 11COMBROOK LAM
OWNER
CONTRACTOR/DESIGNER/EN INEER
MR Rca6.'�' U 1 ON—PIT
0W14ZM=E, R.
45 -6?-5 CO'sDBROOK LARNE
:u Qi,IlN'.`A, (:A 42253
() MIR
USE OF PERMIT
GY."d�1ERAti..
14 LF X O 17126 K14 WALL • CIT i= s57"IOMP.AD
6 PTI WALL 14,00 LF
Sf.i',3�4!b}i,°�'.' D CC?�:i OF CO:lv`iiMUC':f'lt�.'91'�'"
y� gip ��p y� y� y7� �}ry �y,,��5 �p �7:
S"��F:dW.Ml1�S ,S° A�� N0.IJ9'AEVd7AJ1!f. M.
COXOTRUCTION RE. 103-000-41S-000 USA
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LESS 1'J��'- AMYM
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TOTAL 1-TRWr. DUE NOW
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NOV 01 2000
RECEIPT
DATE- /p R
i
BY y
N" �; a
DATE FINALED
INSPECTOR
!i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
Set Backs
Forms & Footings
SlabGrade
Steel.
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wail Insulation
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam s I-% N — — —
1--�,
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
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)
1i
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Final
POOLS - SPAS
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
COMMENTS: