9702-031 (BLCK)_ _ LICENSED CONTRACTOR DECLARATION- — — Y PERM T#
I
� I hereby affirm und:J penalty of perjury that I am licensed under provisions of BUILDING PERMIT !,;7112131.
� Chapter (commencing with Section 7000) of Division 3 of the Business and DATE t VALUATION LOT
U) � 21141 s7 $2,5. 7U
N W Professionals Codp- and `my License is in full force and effect.
License # e-^' Lic. Class Exp. Date
ADDRESS a � I�} AVEN YAelUt`;REZ
I\ cc`(
Z � Zate'�2 Ik o " Signature of Contractor OWNER
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�D �Z OWNER -BUILDER DECLARATION ' �' T1 3-1 V. S
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ D_ License Law for the following reason- / LA QUINTA
CA !M.51
.,
Z_ ( ) 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). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
C0()dam exempt under Section B&P.C. for this reason %'°x gut '4' lh. 501 ch 6' G:rllIWEN BLOCK W1U.L
LO
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
CL
LOQ Z I hereby affirm under penalty of perjury one of the following declarations:
r 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
m< Q performance of the work for which this permit is issued.
Q U I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carver _-S'TA-TC., f j 4 Policy No.z�,�� - Q00%7Z1..
cw Z)
O
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
sjubject to the workers' compensation provisions�of Setion 3,700 of the Labor
Code, I2 shall forthwith comply with tl os�provisioisr'1t-��
Date:'' ~j Applicant 7 �^'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up t $100,000, in
addition to the cost of compensation,darnages 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 snd 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
APN
CONTROL##
TRACT 4711
CONTRACTOR/DESIGNER/ENGINEER
INC
P.G. BOX 11.0
(.A QUfKrA. CA 97253
CRY, es I
5 F71. WALL 58,001_I
C,I.rT. WALL 91.00 LF
S7 ITRUCTPON
11STIMMIP.1) Co. 11 OF
rumsfit(!ar(oN V.im,., teff -000-•4:15-000-
t� 1i' •
�ffI®. 5�.�:N��EJ'C�` CC3V�'1"�Uc,t.'iflhi:tl:�ti�1���!.������.
LESS PRE-Pmf) nm- s
work is not commenced within 180 days from date of Issuance of such 7
'( permit, or cessation of work for 180 days will subject permit to cancellation. FEB 14 I 19999
j I certify that I have read this application and state that the above information is
• if correct. I agree to comply with all City; and State laws relating to the building�� OF
p �1UIN'1'A
C
onstruction, and hereby authorize representatives of this City.to,.enter upo
the above-mentioned property fo�rtinspection purposes. RECEIPT DATE .
OP
_vSignature (Owner/Agent) 4
Tbrf,At PE RNOT'VEISS 111M, NOW
BY DATE FINAL ED INSPECTOR
y
2,505.70
$54.00
556.00
INSPECTION RECORD .,
,3PERATION
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
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
•- Z Z —
Main Drain
Bond Beam
^2
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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 .-
COMMENTS:
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)