0012-228 (PLBG)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 E�xp..Date }
ate r"li
^/ ` ' '' 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.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 owner of the property„ am exclusively contracting with, licensed
contractors to construct the project (Sec. 7044„ Business & Professionals
Code).
O 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
pen '
Amance 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 noFare:
Carrier Policy No.
STATE FUM) 0�4•Ufi!•�t0i4�$4
(This section need not be completed,if the permit valuation is for $100.00 or less):
O 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
worl�ers' compensation laws of Califo a, and agree•tKdtlif I shovid become
subject to the workers' compensation'pr6Gisions,of Section -3700 the Labor
Ccfde, I shall,fortfiwith comply wifF (hO ro ppipn9- .� 1
Date: ' '�' f�/ u'L'' Applicant%! '�',
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties' and civil fines up to $100;0001'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. -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 o9this'City to enter* upon
the above-mentioned proerty for inspection purposes!
Sig ature (Owner/Agent)�"''Y'<=�s� Date fir/
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT TRACT
V,80.00{
JOB SITE
APN
ADDRESS &I—CM AWN) AAr oAS°CO
: 774-1n' -Wli
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MS. 303:x, I? DIL
ID�OER �1TNEOMG & CONST',
53.600 AVENID �� ASM..)
66I 1175 .MMUM COURT
LA QUNTA CA 92253
fGN1°W:aM CTT Y t,".'•;A. 92234
.-060027.22W CRIh _3577
USE OF PERMIT
WrIC ABANWN • M" fW R CONINFXT , b tiW-PliOli3 PR1,11LCT'2000o21..
VALUATION I'S
BJymmum WOv'OF conmwent{n
PEluff'r M SPRY
d'I:tlMINNO RE •- SSR 1101-000-439.000 •
0 Tlls'-1y0'r i. CON'WRUCM09:►AND PLAN 03-IFXX
TMS M�PAIDEFF3
t%,ria
RECEIPT
DATE %
BY-,?"
DATE FINALED
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 & 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 gj""Z
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final s 7
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)