0209-197 (BLCK)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
"I
Date .2610 U7Signature of Contractor
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, 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&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 9TX[p pU;��, Policy No. 1f�61.91 4$
(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 riot employ any person in any manner so as to become subjecyo the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation; proviss of Section 370,0'�of4he Labor
Code, I.shall forthith ggomply with,th exp Avisions.
Date: �era1 <JApplicant .� t:,� G'F ✓�� '( i; _.�''^ ...
Warning: Failure to secure Worker`';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 applicator 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 sucl 6
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 doo.6 -
the above-mentioned property folinspection urposes./r r
Signature (Owner/Agent) 'r f..' Date
BUILDING PERMIT PERMIT JJ
02,04D-3.97
DATE " VALUATION S7
9n, LOT 139 TRACT W52
JOB SITE ' APN
ADDRESS 41.010 lgti AMME - ..
OWNER CONTRACTOR/DESIGNER/ENGINEER
CA14ADAY & awUWANY CA ADAY & WNIPP►YiY
17480 E. 17M SM #106 1740 X 17I•€S 0JM06
°iEt �u"IT�i CA, 9'2'760 1311USI CA 92780
(714)508-4440 Cutis# 4485
USE OF PERMIT
90 L.It ei' &. 19 ;4, fig. V OAR.iYlt:id `631AL , ORCO
11 Pit. . 7 i F=0-
0 rr, IVAL-11 9010011F
EmxAm 2'sY.�St,7#3
G0330 RUCTION i EE l01-000-6,2�;0{)i)
O SUB- !Pd* ���tAM�dAN CAH)ZO- $34.00C 4
LESS PRE -111 ) Fa4 $0.00
i
SEP 2 6 2001 � ..AL PWUS PAIS B W
CITY OF LAQUINTA
FINANCE DEPT:
RECEIPT DATE BY s` DATE FINALE D 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
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
o :-
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final s
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
-Fina-[---
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)