0104-101 (BLCK)is r. IV _wf i ...
LICENSED CONTRAC°TOR�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
C 3 1/2(
Date <! s ..• a Signature of Contractor <r�
OWNER -BUILDER DECLARA-I'ION
I hereby affirm under penalty of perjury that kam 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
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.
CEFIID02.1601
(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 of Section 3700 of the Labor
Code, I sh`all forthwith comply wlfh those provisions.,
Date'r n - ; / Applicant...
Warning: Failure to secure Workers' Compensation coverageds unlawful and
shall subject an employer to c�imirial 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.
1 -certify that I have readthisapplication 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.
ems'
4
Signature (Owner/Agents -Y ^' • - x ` % F ' t' Date •`7• /-2 • 1' 4
BUILDING -PERMIT -
DATE VALUATION . LOT
JOB SITE
ADDRESS
OWNER
52-225 A)leMPxAIA'.,�
TA QT;W `A moi,, 9_1253
USE OF PERMIT J I
10 UP 5° C' 9fi.i+3AMfiT4TAt..t SON iYENCE,
95 UP 5'RKWOOD FENCE
5 FT. WO0D FE N(
51rI`. 'WALL
0164401-'- `TRACT
CONTRACTOR/DESIGNER/EN 1NEER ~�
. ALS ! m, FF—MCE C1ty3J9Mt3M1014
113501D IMIX MORMAGO ROAD
M?=T HOT SPRN-M CA 92240
(761)32987311 M4 763
1
3.1.00V
110.0 LIP
��r3it3 t 113C' lai FRE I W -000-41 6 -OW
e
1
APR 12 2001
CITY
OF LA OUINTA
Flt
ANCE DEPT
SLID-`t:MAL � ONVIRcMIJ014 AND PLAN CI ?,,K
lira PRE -PIM )RIMS
$63.00
MOO
I 4YEAL PIMMI� f2�F WE JIM W
RECEIPT DATE ' BY DATE FINALED INSPECTOR
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
0. 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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond—�
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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:
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