0110-024 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division'3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
G 5 � License # Lic. Class Exp. Date
?3Fit2ff A C1tr�3012g
LLJ
Z i Date Z —Signature of Contra a�O
�O O t�-
J V. 0 ; _.---�–—O�'ll1�R-BUILDER DECLARATION
HWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CL
V) 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).
( ) 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&RC. for this reason
N
Date Signature of Owner
O�
a Q WORKER'S COMPENSATION DECLARATION
p Cc I hereby affirm under penalty of perjury one of the following declarations:.
r H O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W u- compensation, as provided for by Section 3700 of the Labor Code, for the
mQ performance of the work'for which this permit is issued.
Q U(� 1 have and will maintain workers' compensation insurance, as required by
O U Q on 3700 of the Labor Code, for the performance of the work for•which this
Il H = permit is issued. My workers' compensation insurance carrier & policy no. are:
? Carrier WATE F1UWT) Policy No. Imn-00
ao �
r` CY
g (This section need not be completed 9 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
3 subject to the workers' compensationQvisions of Section 3700 of the Labor
Code, I half hwith comply wit ro inions.
Date. �� Applicant
""Warning:Failure to secure W6,rkers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the. cost of compensation; damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT .Application is,hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person -Upon whose behalf this application is made & each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of Issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above Information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspectjon purposes.
r
Signature (Owner Date,
BUILDING PERMIT rt"M11 F
0110-024
DATE IOA131m- VALUATION � s,so LOT fir; TRACT 258
JOB SITE ADDRESS ;,"_()40 AJYF,fiDA C0.15.�Z APN 774-11,92-=
OWNER
3137 0 AVEMi-k BERM)DAS
LA•QUftriA CA 52253
USE OF PERMIT
CONTRACTOR/DESIGNER/ENGINEER
r'(i)t,]'i'%l!tf?i7Tt�y I10WIS
51370 A'lEA1I1 A F31 U�ML•sDAZ
Lai.QU.INTA CA 92253
,,-70)564-1962 CD14 625$
.51 LF WALL 5' WJZDF.N iWA.1.L & 14 1,17 X 4' OjUME:N WA
5 F', FJ,AU,
4 PT. WALL
50.0 fF
14.40 LY
ENTIMA17D COST 01" COMMUMON
Ct;?N8'1AUCTION M, 101.000-116.1000 $33.01?
OCT 0 3 2001
CITY OF LA OLIINTA
FINANCP O–PT
5
�.'L1B-1,tYT`,P,lf.. CONS UC,''• ON ,AN1.17�LA Cf;. + 33.t2t1
RECEIPT I DATE
11MM, )W_1ITINS DUE .NOW 1 &.3„1,0➢
INSPECTOR
HSIPCCTM RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BULMNG APPROVALS MECH iR CAL APPROVALS
Set Backs Underground Ducts
Forms & Footings Q �_ 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
��S Final
Finai I d��_ POOL S - SPAZ
_ Steel _
Sei Backs 6—Ib`p� Electric Bond
Footings V Main Drain
Bond Beam Approval to Cover
Equipment Location
Electric
_Underground
Underground Plbg. Test
Final _._-__ �_ Gas Piping
Jl�l�iC�3J� PO�w�� Gas Test
_ _ Electric Final
VdLi
aste nes m Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Eco p nfayclosure
Shower Pans
'O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
_
Sewer Connection
Encapsulation
pp
Gas Piping
Gas Test 7/b
Appliances /
_
Finai
COMMENTS:
Final
Utility Notice (Gas)
EL IECYMCAL 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)