0301-332 (BLDG)LICENSED CONTRACTOR DECLARATION
I here' zffirm under penalty'of perjury that I am licensed under provisions of
Chaff (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
'733152 B HIC, 3/31103
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:
( ) 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 & Pro essionals
Code). /
() I am exempt under Section �.B&P.C. for this /reas9fi
Date Signature of Owner-,
1 �1
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 ?4`WI'S F►)`pjji Policy No. 04,60110MT000940
(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 prgvisions of Sectigrf700 of the Labor
Code, I shall forthwith comply with those/' provisions.
Date: J/ -"Applicant ('
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)
PERMIT PERMIT#
DATE0,BUILDING
* VALUATION. LOT TRACT
JOB SITE
ADDRESS BJAX;1 3.15 LIUMPIONS–T?T�'ERA.. 5�( '�� J
APN r
OWNER
CONTRACTOR / DESIGNER / EN INEER
PGAt!.S'd R EMD1:AWMAL AM—)C., WC
DE, L M_kR. PP:c;'.(i`IC C3W. _MAL CC)Wi3W'i'0
P:CO.11OX 1060
2.533 ,Jt7'Crfll CCJAo7T' l:Cf(-TW.AY:TS`.E: 250
CA 9225.3
C°AtRDIFF S;3i' TIE RA CA 200
(760)6351010 C1J%F' 5823
USE OF PERMIT
FILZO. 75: X;x..54.916, Vf;3.l,tJld`!'.AitY STRUCTURAL
ODINt;,AT'IOWS
VALUAT1011 IX
.1"wo.Ult_I .
CrC7Na'f.i UCTION MS; 101.000.418-000
S3'l2ca�fir faBC�T'lfvf+tl ►�:� - ItA•S3to S i> :I-C�l3E,1- Zd 1-itQ(S ^�.'�f►
FEB 0 3 �UU3
CITY OF LA GIUINTA
FINANCE DEPT.
W 1;3=W)TAL•CC33�1'2 ? :Z'[rC'''Y.ZUI+S AAi1(5 .�'I. �' l�7 C!!nEC". K
l0
$90.110
JA"Tss; rn.P&D.FHr;'J
$0.00
dMilL S EI11)f I sy�'�t7� ME NOW
RECEIPT
DATE
BY_
D E FI LED
INSPE
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
i
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steei
Set.Backs
Electric Bond
_
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
.i
Underground Electric
Underground Plbg. Test
at
Gas Piping
PLUMBING APPROVALS
Gas Test
_
Electric Final
Waste Lines
Heater Final
-^
Water Piping '
Plumbing Final
_
Plumbing Top Out
Equipment Enclosure
_
Shower Pans - w
_ _
Q.K.. for Finish Plaster
Sewer Latera! - - - �
Sewer Connection _ -
-- � Pool Cnvppsula
_Encapsulation
-
Gas Piping - --�
'
--
-- -�
Gas Test
-
Appliances
-�—_
-
---
-
-�--
—�
Final
- ----
— COMMENTS. -
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
f
,
Low Vctiage Wiring ^~
-
✓ ^� V / r
FiAL-es
Main Service
Sub Panels
Exterior Receptacles
Pern.oke Detectors
pUse of Power
Final
Utility Notice (Perm)