0301-376 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Imo— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
=) ch License # Lic. Class Exp. Date
� Q In
LLJ '?3 31.3 F3 L fI3l31 � C
oZ r- Date Signature of Contractor
tfl0r
J U OWNER -BUILDER DECLARATION
LU H WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
(;e) I, as owner of the property, am exclusively contracting with licensed
,,"contractors to construct the project (Sec. 7044, Business & Professionals
Code)Jz(ef
'
Cl) rO IPx under Section B&P.C. fo this rea n
)'F ,! Signature of Owner°
O N ul
'"� Date �.. :.`;�
d Q WORKER'S COMPENSATION DECLAR ION
p Z 1 hereby affirm under penalty of perjury one of the following declarations:
Lo H 0 () 1 have and will maintain a certificate of consent to self insure for workers'
X W 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.
CQ Q U () 1 have and will maintain workers' compensation insurance, as required by
Q U Section 3700 of the Labor Code, for the performance of the work for which this
13� LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
It z Carrier Rf•1'.f Tp.; Ffry)4j> Policy No. 04001'O3-NITt1ONIS
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(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 should become
3 subject to thew rkers' compensation provisions i ' C /3700 of the Labor
Code„1� tt' o th comply wit •those rovisi s. �.
Date: °%' Applicant �� -
t
Warning: Failure to secure Workers' Compensation coverage is unla'Wfu I 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 thg above information is
• correct. I agree to comply with all City, and State �ws re�lating to the building
construction, and hereby authorize represpritat'vps of this City to enter upon
the above-mentioned property fqr inspecti fn pses. f
L.�
Signature (Owner/Agent) - - -' 4 Date if
BUILDING PERMIT PERMT�
DATE ` VALUATION LOT TRACT
JOB SITE
ADDRESS d.1 C&.3► k dC 1 i:� ^ mum t-5—irl 78 I
APN
.
OWNER
CONTRACTOR/ DESIGNE R/ EN INEER
PGA ;7 , TRCCJDerAI, fc:Y
f�T, �IAR PA „ GYXLRp V0winl7y✓
P,o. Bax 1 660
2533 CO�`�T ki1Cr�? 4�'.�Y a rl� 250
1,A QUraTA CA 92253
ClARD FSY” TTWF SRA CA 92007
f.,760)6315»1010 CBW 5823
USE OF PERMIT
OPIM4W. Bil<.fI' )>:t G
EibM 35: 54.70, 54-7RI, 54 -IMS. VOIX14TARY STRUCTURAL
MODfNL"ATIONS
V.a9JAI.l TION 151000." Lai
-E911MATW COW OF C0KSrM1.TCn0N
vs, (M W
PERWT IrFaill SUMMARY
4;'ONS' fllUCTION FEE 101.000.418.000 �d162.�t
sT-p, ` l4a mt;a`f uaw rro RE IO .1011-000-241.•ON) i. reit'
3 7003 Lqu
qCIFT1yNANCE
A QUINTA DEPT.
9r_M-T(Xr)%1., C" ONIST"fiIM-111CjN AIzd'I3 ?"l:,AyW CMA71fb =
$163.50
G ms P4Z&Vhb FEF..q
$0.00
NOTAL PE'1 rI lMES IRAN :i+tOW
$16131'50
RECEIPT
DATE
BY15
INSP TOR
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
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
Final
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
r •
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)
COMMENT
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