0011-164 (BLCK)LICENSED CONTRACTOR DECLARATION
!9 1 hereby affirm under penalty of perjury that l am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
.� W Professionals Code, and' my License is in full force and effect.
O =) M License # Lid. Class Exp. Date
1�CY� i
LLI
S C20 -C-1
oZ VDate ' /I� 'k Signature of Contractor
CID0.
J U coo OWNER -BUILDER DECLARATION
W. W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~.tl License Law for the following reason:
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).
( ) ' l,. as uwrier of tn2''p'r6perty, am exclusively contracting with licensed
contractors to construct the project (Seca 7044, Business & Professionals
Code).
C0 O I am exempt'under Section B&RC. for this reason
LO
N Date Signature of Owner
0 ,
U Q WORKER'S COMPENSATION DECLARATION
CL —
p CC I hereby affirm under penalty. of perjury 'one of the .following declarations:
Lo 0 O 1 have and will maintain a certificate.of consent to self -insure for workers'
X WLL compensation, as provided for by Section 3700 of the Labor Code, for the
0 J Q performance of the work for which this permit is issued. ,
Q (�. ( 1 have and will maintain workers' compensation. insurance, as required by
p Section 3700 of the Labor Code, for the performance of the work for which this
U
' ,O U H permit is issued. My. workers' compensation insurance carrier & policy no. are:
t Z Carrier Policy No.
o o STATE FOND 2�0-tin �Qao3S0
J
(This section need not.be completed if the permit valuation is for $100.00 or less).
O 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
1 subject to the workers' compensation provisions of Section 3700 of the Labor
•x•77 Code, i shall forthwith comply with -those provisions.
ate://./16626 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.
T
IMPORTANT Application is hereby made to the Director of Building_and Safety
'for a permit subject. to the conditions` and restrictions set forth on hjs
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.
Sig ature (Owner/Agent).41 �-- y`dt: rte`" Date `f � "'
BUILDINGPERMIT PERMIT#
DATE VALUATION LOT' 003.1.-164 TRACT
JOB SITE
APN
,ADDRESS
le W-345 ,A'd�,&�kDA N V Pk�.�
OWNER
CONTRACTOR/DESIGNER/ENGINEER
4 it.
1 C4I ?i i 1. > b'J" r4CJRI
BOX 2982
718-921 RUNAWAY MY
PALM DEMIXT CA 92261
IBMWEIADMES CSS, 92263
,7CU)§ t9-8700 C,'.L�' 1526
"
I ISE f1F PERMIT
651,F )l. Y GAieVEN WAIA, &90 L F dtitr YAR.6'3 RY7ATitiPt`.NE3 6' VdA1,,L -
OITY ST.ANF3ARD
6 Y71 WALL, 30,00 !.F
5 MI. WA.0 65.00 i,P`
• VnTA�a TKD C O (IF C;€�.��a'xi'�xUC.'`�'0.�
1:°asmur"f)C'N Yva? 101 -000.4) S -OW $0100
STOT tyC� �•Cf��;"l:IC`lAt AMP .�,�t CHECK'
$63.00
S
RECEIPT DATE �'` r c) ,j
BY+•'6 y4
DATEFINAL ED
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
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 BacksQ
Footings ��
Electric Bond
Main Drain
Bond Beam `/ �� ��C
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
OX 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)