0301-320 (BLDG)LICENSED CONTRACTOR DECLARATION
I her ffirm under penalty of perjury that I am licensed under provisions of
ChapW (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
733652 'P JPO IN t3y'/p
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).
f(e ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Seca 7044, Business &, Professionals
Code). f , !/
O I am exempt under Section B&P.0 for t 'is reason
Date 1 - t -� . J Signature of'`OWner,""` 7.
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.
(f,) 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 STATE ITUND Policy No. t 40I M41TVtt90M
(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 if10I, should become
subject to the workers' compensation provisions of'Section�13700 of the Labor
Code, I shall forthwith comply with.thoswprovisions.,
Date.' ! " -�I • :.� -:� Applicant �:..-.1 "•_ •,•-J
Warning: Failure to secure Workers' Com pphsatio/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/rfior insJp/eeZZ
ppurrposes. •,
1 ....E-1 A,.. y> A -Signature (Owner/Agerit)�H /1 Date 1 " -71 ' c �
J +
BUILDING PERMIT PERMIT#
(Ys
DATE / VALUATION. g,�,��•� LOT TRACT
JOB SITE
ADDRESS fiJAXU� s A �U1ltifPIONS -RPAMA —5-5-45 D
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
f 10 AWEM" REWDEN'1;ML ASSOC., :WO
DO,R.��? F���Iti QE`1�ERAL C014TRAMOJ
P.01,DOX 3060
2533 SWTO,CSO r111GH a`• Y NMS. 2-51)
LA OY XWVA CA ;9225 .t,
CARD1V I T TW , 9 Cdr,M0
Q60)635.1010 CM16 5823
USE OF PERMIT
SLIXf. 23: 55-470,53-460,55450. V(5)::W4TASt,Y S' 9.UCTM R.AL
ODIFtG'•:x'i:TION
VALVAT ION LAS
�1'�ti?n��a�p'rtsstt.�'��-.rc:�.�ila 'Iff1-��(�-���>Crf3U � •' $t.f3�i
11-7
CITY OF LA QUINT►
DEPT.
FINANCE
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RECEIPT
DATE
BY" _.
DA
INA D
INSPE
R
?S,
INSPECTION RECORD
OPERATION DATE INSPECTOR
• BUILDING APPROVALS
OPERATION DATE j INSPECTOR
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 3
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 Plbg. Test
.al
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
.F.I.
,oke Detectors
temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
✓/� -71/4 3
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