0105-235 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (conirpencing 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
C39
WC 2ifC
Date ' 'f Signature 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 wagesas 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:
Carrier Policy No.
:lad
FUND it�9•�1-if0p&��
(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
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 9, the Labor
Code, I shall forthwith comply with those proyisioris?"
Date: ' _ ^ �.� Applicant _ -/ /-;i
•^ Wgrning: Failure to secure Worke4lCompensation 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 inspect`on,purposes. ^'
d"
i
St) Signature_(Owner/Agen- -� °f�� 3Z� Date ''.r.r
BUILDING PERMIT PERMIT#
DATE _VALUATION LOTTRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
.R,iJRM.AIJIMON
ADVANCED Ft0e7FIRC3. SYMW
51407AVY01H)A.WIMC O
54314. M6?A1TOY,YRE),
k...A PPIN'1 A. CA 9225.3
PAT O1`t7 M CA 92263
060)320-7310 Mik 4053
USE OF PERMIT
RE-,ROOV CLASS , t, MATERIALS
TILE PER JCB0 WORT VR 3523
f."1..f4,YLITF
RSROO 151513.04 ERZ
�u'S"s AIED COST OF C;t.�Y�S:tC'R'GQ:" ON
asp 1�7yyx yry qp p'�,y,�;
P C 11 LRE, 655.11'F2A/.itSR y
UROOFFUE 101-000-418-000
" al C,C3Itit'S1'MMt9N AND PLAV CII. tiJCK
$30.00
:[SSS -PAID FEE, 9
$0.00
T: MS .1311E NOW
MAY 2 1 200)
M100
CITY OF LA_ Oul4TA
RE C 'PTi
/
BY
DAT NALE
INSPECTOR
f/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
I.INSPECTOR
i BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Feims & Footings
Ducts
Slab Grade
! Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
i Compressor
Insulation '
s Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
t
Exterior Lath
Drywall - Int. Lath
.
i
s
a
Final
Final
BLOCKWALL
APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
j 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: