0301-327 (BLDG)U)
LICENSED CONTRACTOR DECLARATION
I her tffirm under penalty of perjury that I am licensed under provisions of
(commencing with Section 7000) of Division 3 of the Business and
PERMIT#
BUILDING PERMIT X,.�fry
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Code, License is in full force
DATE VALUATION $j+.C!> 11 LOT TRACT
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Professionals and my and effect.
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License # Lic. Class Exp. Date'
7331.52 D 11.1x: 3/31/03
ADDRESS S I�Ja.1. 0.. 30 CJOB SITE'%i.� TPIOXS ••}''.b9'�T.>!+:. A
55-070
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OWNER
CONTRACTOR/ DESIGNER / EN (NEER
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Date Signature of Contractor
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PGA 14.T RfAW1I, AMC, INC
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OWNER -BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
alt CA CA, 92233
t; :l�f . I;� 1.4 1.•:+.!'!A CA 92-001
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License Law for the following reason:
(76fi)�;35.in�0 `'13L11 5$°i
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( ) 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
USE OF PERMIT
sale (Sec. 7044, Business & Professionals Code).
( ,) I, as owner of the property, am exclusively contracting with licensed
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.contractors to construct the project (Sec. 7044, Business & Professionals
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Code).
I Section B&P.C. �Or t Pg/ reason
iFii.UCT"30:3?J.01S0. iPUkUI!J7'P,1t.YSi.RUti�i11RA1.
am exempt under
MODI ICATIC'iNS
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,,Date �1. A I >, Signature of Owner--•
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
V.A1..UATION 7,000,061,6
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() 1 have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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(,) I have and will maintain workers' compensation insurance, as required by
O U QSection
3700 of the Labor Code, for the performance of the work for which this
issued. My insurance &
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permit is workers' compensation carrier policy no. are:
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Carrier STATE FMID Policy No. 046+1) UNIT00094I S
R-49 ,CLT4rI.�A'1CFD t`i?NT OF C.' ONM1JMORCIS
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PICRWf M. SUMMARY
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(This section need not be completed if the permit valuation is for $100.00 or less).
CO2 STRUC'! IUN.
() 1 certify that in the performance of the work for which this permit is issued,
STR01,4 l M4)9 ION glrl' - RKS10 ! 01 6 J-7/19. -000 aXt
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 with ase pro ssdons.
Date: � ^s I_ `..• Applicants!;
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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
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addition to the cost of compensation, damages as provided for in Section 3706
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of the Labor Code, interest and attorney's fees.
CITY
IMPORTANT Application is hereby made to the Director of Building and Safety
OF LA QUINTA
FINANCE DEPT•
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
iU1E-'.l'CC A1_ C0N1rJ°RLTI`Tl0 )4 A90 VT,,,W C}•Wti; c
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Z90.70
whose request and for whose benefit work is performed under or pursuant to�'Ieis-:F,�II?%._�Lry
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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
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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
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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 inspecti n,purboses.
RECEIPT
DATEJ
BY
D FIN ED
INSP R
%'Signature (Owner/A�ent) ^� Dates "-/ ` �'
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y .�..
INSPECTION RECORD
OPERATION
DATE I
INSPECTOR
OPERATION
I DATE
I 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
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
" alGas
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:
WPM A41k
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Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Recaptac!es S
_
oke Detectors
emp. Use of Power
Final
Utility Notice (Perm)