0112-050 (SFD)LICENSED CONTRACTOR DECLARATION
.1 -hereby affirm under penalty of perjury thatil am licensed under provisions of
—
Chapter 9 (commencing with Section 7000) of Division 3 of the BuIisiness and
Professionals Code, and my License is in full force and effect.
N Lic. Class le
License # Exp. -Da
7340554 A0 MC 3131103
5 tor ---K' —J.
O'Dale 1. Signature of Contr6'
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 I
( ) 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).
1, as ownertof the property; am exclusively'contracting with licensed
contractors to con�truct the project (Sec. 7044, Business & Professionals
Code). . , /11. - 1. . .
O I am exempt under Section - B&P.C. for this reason
Date Signaturg of Owner
WORKER'S COMPENSATION DECLARATION.'
I hereby affirm under peiialty'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
S96bon 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
Mgp Policy No. WC =06 lay -03
(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
wdrkers' 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:, Ap'p lic
_
Warning:'Failure to secure. Workers' Compensation coye-r�e is unlawful and
Ines
shall subject an employer to criminal penalties and civil fines p-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 hW.
application.
1. Each person upon whose behalf this application is made & each persori at
I
whose request and for whose benefit work is performed under or pursuant tQ i
any permit issued as a result of this applicaton agrees to, & shall, indemnifl.
& 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.i
_work is not commenced within -1180 days from date of issuance of suct
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 .iL—
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 inspection purposes.
°Signature
Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 7 TRACT
&
JOB SITE
APN
ADDRESS_ -W
MIANTSH DAY
-7059-0534*3
70YNER
CONTRACTOR/DESIGNER/EN INEER
24-2160WARDL0W (=W, KIM 150
2.280 WA=L0VVC.M0LF,,.VNR 150
COR(YPTA CA 91720
CaRDNA CA 91'f20
(909)279.4,(YJO CKA 5761
USE OF PERMIT
WNGLE FAMLY DWMW46
SYD - 1.0T.75 PI -IM 2AL. MR.'MIT DOES 740T INCLU= RMCK NVALIA
POOIRPA 0R DRIVEWAYAPPROA011,
A,
CUSTOM CONIRRUCTION 203100 OF
PORM. WFAX10 300.60 sp
(JARAMCARPOU 651,00 OF
EstMINIM'D cosT UF coxanuanon
248�W.W
CONSTRUCTION YZE 101.000.418.000 si"161.09
PIA14 CH'MIX 1+'"1' 101-000-439-318 $050..92
101.OW-421-000
ELIft,'TRICAL FW, 101-000-420-000
VA)MR1100 FEE -101-000-41P-000
STROPNO MOTION PAR - RESHID 101 -000-241 -000 $A.63
101-000-423-000 $20,00
INYR.&STAlYMURE FEE 22.5 -43N -443-M sli'mm
ART jw muc m.-Aw kam ro-oop. -445.000
-M-IM MONIETTRITMON AINTO III" C'MM"K.
$4,66A.65
LESS PRE-FAMEIMB
$0.00
DEC 113:2001
MAMAS:
YCIFLAQUIWA
RECEIPT
DATE
BY(L_:Zt F1 E
SPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
GATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs_
Underground Ducts
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap6Q/
Framing
Insulation
Fireplace P.L.
- 6
_t)j�i e f
�7! ~Compressor
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Vents
Grills /
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
S_ l�6Z
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
_
Final
PLUMBING AP " OVALS
Waste Lines /9� �� g�,�yl�
Water Piping
F ilpment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
/
9�a
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
_
Final
COMMENTS:
�L�9L iIo ff/ ' /l Z 11A
Final - — -
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures /—
Main Service
_
Sub Panels
_
Exterior Receptacles C
G.F.I.
Smoke Detectors /47
Temp. Use of Power /
Final
Utility Notice (Perm)