0209-200 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions
Chapter 9 (commencing with Section 7000) of.Division 3 of the Business ai
Professionals Code, and my -License is in full force and effect.
License # Lic. Class - Exp. Date
moi: m l R . /31 /€*
Da / ` Signature of Contractor0//
Of
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that Tam exempt from the Contracto
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sc
compensation, will do the work, and the structure is not intended or offered I
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licens
contractors to construct the project (Sec. 7044, Business & Professions
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 declaratior
( ) I have and will maintain a certificate of consent to self -insure for worke
compensation, as provided for by Section 3700 of the Labor Code, for tl
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required
.Section 3700 of the Labor Code, for the performance of the work for which tt
permit is issued. My workers' compensation insurance carrier & policy no. ai
Carrier STAi°RVU14D Policy No. 1+6613,01-01
(This section need not be completed if the permit valuation is for $100.00 or les
( ) I certify that in the performance of the work for which this permit is issue
I shall not employ any person in any manner so as to become subject to tl
workers' compensation laws of California, and agree that 'f Vhould becor
subject to the workers' compensation pr6visiion` f Se.&tioK 3700 of the Lab
Code, I,'shal(forth if 1, comply with those pro�ISloVDate: ��{"sCC..�r Applicant ,2'6i. t-
Warning: Failure to secure Workers' Co pensation coverage is unlawful ai
shall subject an employer to criminal penalties and civil fines up to $100,000,
addition to the cost of compensation, damages as provided for in Section 371
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and, restrictions set forth on t
application.
1. Each person upon whose behalf this applicatior�,is made & each person
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemn
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and voic
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellatic
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating to the buildii
construction, and hereby authorize representatives of this City to enter up
the above-mentioned property for'I,n§pection purposes. c �
Sig (Owner/Agent) "� Date
of
BUILDING PERMIT
PERMT#
id
DATE VALUATION: LOT
I
w
TRACT
142,
Z6 l 52
i
JOB SITE
ADDRESS 47,045 NM AN TWIES
APN
-
OWNER
CONTRACTOR/DESIGNER/EN INEER
1746.0 X. 17TH STA 06
12480 T3, 171H VT. 41 W
s
TUSTM CA 92 7/80
IVIWIN, CA,
92,780
le
(714)508,, 440 MA 4485
or
USE OF PERMIT
)di'si�&.�.J
IIs .
100 L.3°', b' &441,.19: 5' 0AP-C)11;N',VAIA, ORWO SYS`iFM
s:
s
4 F?', WALL,
Id)f AIA LF
5 F"1'. Vr.&L.L
441.00 LF
ie
Dy
Iis
e:
ESMATED COST ON' C 0111 MUMMY
3,452.60
.ilk -1 I` f x.`- 4a'iDMATA Y
s)•
CONSTItUCTI+w N YZE 1011.000.418.000 1;63.6t0
d,
ie
ie
or
id
in
)6
.v Fx
is=y
>.4
v
at"
iS`GT1 -TOr. AL 16014MRUt , '1°JEOX AND PLAN CR X
$63.00
t0'`.
ify,
� Q •• '� •
�R
j"S PR V ' AED �
$0100
�s.
if
d IMR1 T70"
DUE NOW
k*
n.
SEP 2 6 2002
�n.
is
CITY OF LAQUINTA
FINANCE
Ig:.,c
DEPT
m
/��.
RECEIPTh
y'. <
DATE., /
• / !'7 y�-
B`��
-'^---..'�`^_•--_...-.�..
DATE FINALED D y
1-111_ ' /
INSPECTOR
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
0. 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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
- W v s
Main Drain
Bond Beam
to 4!�o p a- S7
Approval to Cover
Equipment Location
Underground Electric
Final
1�� r . O %
Underground Plbg. Test
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
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)
COMMENTS: