0204-133 (AR)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 and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
734.094 .A,B?r C � 34�1l03
Date z it"- Signature of Co t actors
n,✓.. yam; =
OWNER -BUILDER DEC ARATION�"�
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 employee.s.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:.
Cartier w 3 JC11J,WEJUCA1J Policy No:.
(This section need not -be completed if the permit valuation is for $100.00 or less).
–(–)–I-ce rtify,that-in-the-performance-of-the-work-for-wh ich-th is -pe rm it -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:Applicant
Warning: Failure to secure Workers' Compensation coverages unlawful and
shall subject an employer to criminal penalties and civil fines up t6•$100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth onr•his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. L
2. Any permit issued as, a result of this application becomes null and void i
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives;:of this City to enter upo
the above-mentioned property for inspection purposes -
t't{ow ry
s AF s �2 } y
Signature (Owner`/Agen— ~"� Date
• �.. r :.._. r.Y.'i5' y ..
BUILDING PERMIT PERMIT# "
/ ^ 2• 33 ;
DATE VALUATION LOT„� 4 .., ..� ., _ ' TRACT
ADDRESS
, ,�A. s�lR19A. JOB SITE ao7
APN -d �w• � ' s�J{ '�S
OWNER
CONTRACTOR/DESIGNER/EN (NEER'
�.�6TrYnows
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Gf'C8%10-
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'2280 YpyDOWr nI�tJ'9 15
MHD1tiACZry py in. s t ✓
COROIJA CA,, 91120
CORONA ;.:CTA 91720
t909,09-4000 -. IR 5761,
USE OF PERMIT
RFUR$ENTLA,LAMMON
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LOT --42, "A% PIAW-C"'N-F K -PEE AF,DUC TIC' X F!` R MUL I TPLE ISSUANCE a• ,`
OF SAME PLAN TYPE
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13.52:5160
PERWI Z1`14`E 90 AUlii RY
1'%Aa CI1a'.CiC 'EE I.C►1 QUf?(1 439°31 S8.73
ELECTRICAL AL IYEX 101.1000,420.000 5148
PLUMBING FEE 101 -girt? -419-000 �Ci,i)rJ
SOT R0; M OT10,,NJI E `RES ID 101-000-241-000
.ART T.1d PUBLIC PLAMS - P.ZSII:270-000.443-000
SUB -TOTAL CC71*T►1'1i2Y3'C"°1Tt7:tJ'PLANT CH=
roTAL r.sromr mm' S* Dog NOW
M07
i
MAY 0 3 7002
CITYOFIAfdU1NlTA
FINANCEDEPT.
RECEIPT
DATE- :,
BY
DATE FINALED
INSPECTOR
•
y
i7 I'i J-•
10
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 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
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)