0101-157 (BLCK)LICENSED CONTRACTOR 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 a
Professionals Code, and my License is in full force and effect. G
License # Lic. Class Exp. Date
370768
Date Signature of Contractor—4
C' fey.
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 & 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 4 Policy No.
(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 shall forthwith comply with those.provisions: ..
Date: is°- • !t ° Applicant" w ;°"� "` Y%'�^ ^•
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,
uilding;construction, and hereby authorize representatives of this City to enter uponr
Pe above-mentioned property foUnspection purposes.
Signature (Owner/Agent) Date`
+-
BUILDING PERMIT PERMIT#
AT J j VALUATION LOT 0101_ j'l TRACT
J . /
JOB SITE
APN
ADDRESS
W-1815- WS11.1,10 COURT
OWNER
CONTRACTOR/DESIGNER/ENGINEER
150-811 I TSF':ERCrot. lrll
4.500 GRAND CANYON LWS
1A,QT):iArfA CA 92253
PALMDWOR17 CA 922643•-Y
(7-i0P76-4215 MIX SWI
USE OF PERMIT
4:aa.C:"Abl�d' l�L• ���D: Y.�sl�" Li
14M0 Iry 1 X* '(j):(�Ei1syO� t?1�ltA� RDEN 'ir�.ALI.. • OPIC0 SYST)�k
A .L X31 «9f.1OCK y�T.A5' L
16 p°r.WMIL, 144.00 1.F
UANAMM COST 010 CM1.✓A6%'YRRJ'4MAIOX
e�'r:,'1.94A.179J
•� [� 1 n�y{� q •�SpS�eyi
CONO 3t.UM104% FEE 1-01-000-41B-000 -000 fib: AD
a
9
p
USS PRE-PIAM YOM
$0,00
TOM 11KI.4'AT IT.7:UN RJ5.YE WC''V@
apSYa�aR94�
JAN 12 2001
.;1TY Y vi7LA uU0 1
RECEIPT
DATE/1
By—„i-y
DATE FINALED
INSPECTOR
k
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
- 'BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I {
Underground Ducts
Forms & Footings",
Ducts
Stab Grade { }
Return Air +"
Steel I {
Combustion Air
Roof Deck 1 { g
Exhaust Fans
O.K. to Wrap I1
F.A.U.
Framing I, t
Compressor
Insulation {
Vents .
Fireplace P.L. I }
Grills
Fireplace T.O. 1 I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall, I
Exterior Lath 1 I
Drywall - Int. Lath 1 t
I#
I {
Final
Final Ii
BtI OCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs 1 { =��- �� �L�
Electric Bond
Footings 1 I
Main Drain
Bond Beam I I
Approval to Cover
I {
Equipment Location
Underground Electric
Underground Pibg. Test
Final { 1
Gas Piping
PLUMBING APPROVALS
I t
Gas Test
Electric Final
Waste Lines { }
Heater Final
Water Piping I }
Plumbing Final
Plumbing Top Out I i
Equipment Enclosure
Shower Pans l l
O.K. for Finish Plaster
Sewer Lateral j }
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping { {
Gas Test i
Appliances i }
{
Final
11 .
li
Final 1 I
Utility Notice (Gas) {?
ELECTRICAL APPROVALS
Temp. Power Pole I I
Underground Conduit:
Rough Wiring I'
Low Vottage Wiring ; }
Fixtures }
Main Service {;
Sub Panels { {
Exterior Receptacles I {
G.F.I. I {
Smoke Detectors {
Temp. Use of Power) I
I}
ii
Final { {
Utility Notice (Perm)
COMMENTS:
"
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