0109-170 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F— Chapter 9 (commencing with Section 7000) of Division 3 of the. Business and
(V W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
~ W
oZ Date `' Signature of Contractor
CD 0.�
�
I.—
CD OWNER -BUILDER DECLARATION
W W t` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ c-
coLicense Law for the following reason:
Z ( ) 1, 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).
M ( ) I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
U Q 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 Policy No.
MATE FUND W"09-00
(This section need not be completed if the permit valuation is for $100.00 or rless).
( ) 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 Call ornia, and agree that if I should become
subject to the workers' coinpensati - n provisions of Section 3700 of the Labor
Code,rl�halgtorthwith comply with."" ro isions.
Date: t ° I 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.
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.
1 certify that I have read this application and state that the above information is
correct. I agree to comply with II City, and State laws relating to the building
construction, and hereby autho ze representatives of this City to enter upon
the above-mentioned property,f r in �ection purposes.
f Int
Signature (Owner/Agent) �,, Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT Qy� Q� } �Q TRACT
'9 I X 91? it: r '
JOB SITE
APN
ADDRESS
-040 Ati Ri+MA (ICY.(177'
OWNER
CONTRACTOR / DESIGNER / ENGINEER.
P1 710411411 all,(" G0
1401hk,S
.).BQ,K 1141
51370 AMMILDAB��"CiiWI1)AD
LA QUk1>1"TA lir° 92253
LA f}d:3MA CA 9225,-,'
(760).SCA-1962 10MR 6255
USE OF PERMIT
Pl"?OL ANWt, R SPA,
KYJ1, ORLY. hLARUMARRIERS SHALL BE 1N PLAC1>: AT PRE-PLNSTIM
1148Pl•;CT1014. PYXyL FOUiPWNT F3}iCLOSURE NOT tMCl.tfl:)ED
'l/'At..f,f �3,.TlUt� tii,S�A,fff�
EiH')('11l1KrF_ a Cc= Cor G£}n6mUC;"1'io.n
4i,�4D.tEt9
;['JlluiQ:A` �` �ii711�5ry
PLAN C-111ECK WE
CONSTRUCTION KEE 101 -titd" 1 8 -WO $9G.C1f►
IrUC'1 TICAL nF, - P001. 107-000-420.000 ff�15,04
c . PLUNIRD40 >PXK .< POOL 161-000.419-000 �f67.4t➢
SEP 19 2001
CITY OF LA QUINTA
FINANCE DEPT u�
#lllrs-:t'GTIU.CCHMV1 11C'T'i0 ANDPLM031C".€�
$2tti3..5t1
LES,Y'�'&PAED F13P.St
!i�f3, Uca
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
RSPECTM RIECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BNJOL UMG APPROVALS
AECHQMCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air__
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap I
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
Steal ---
__—
Set Backs—
i- ---'
Electric Bond
---
Footings
Main Drain
Bond Beam �
—
Approval to Cover
_
Equipment Location
Underground Electric
Underground Plbg. Test
Ftnel _ _ _
-----
Gas Piping
-
Gas Test -- —
- -- —
----
Electric Final
_
Nilsie tines
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)
GLECMCALF 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)
so' CORTEZ