0108-156 (BLCK)LICENSED CONTRACTOWDECLARATION
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
Date 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).
( ) I, as owner of the property,- am exclusively contracting with licensed ;
contractors to construct the project (Sec. 7044, Business & Professionals'
..
Code).r�,
O I am exempt under Section B&P.C. fora is.on
Datel)e .t��,l�is Signature of Owner-",'-' J!\ re � M_
LARATION
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. I`
(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 sued,
I shall not employ any person in any manner'so as to become'suliject to the
workers' compensation laws of Cal iforn6;,�ad egree that ;if)should become a, '
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with,thoserovi§ions'"''�
X
Date:l �, -1�e N Applicant X�
Warning: Failure to secitre Workers'ICompensation coverage is unlawful and
shall subject an employer�to•cnminal 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, indemnity
& 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 But ho iz 11epresentatives of this City to enter upon
the above-mentioned pr rty for in"spectid purposes.
Signature (Owner/Agent—_'r �..' �z Date<'C .°6` C!
BUILDING PERMIT PERMIT#
DATE VALUATION LOT.. TRACT
4.1
BTAC22811262
JOB SITE
ADDRESS
MI -670 AVEiM . 'VEI,��k SCO
A
7713 �d37'
OWNER
CONTRACTOR/ / EN (NEER
52600M 00M)AIMMMA
52-00
-
L€a.QCe"vu t.°. A- 922.53
U QUWi'A
CA 92263
C?69)564-6515
CM4
USE OF PERMIT
50 YY CIAR1DM °sy*r's.I oCITY STAIMA )
nni
PEAU(14
2002
' CITY
F LA QUINTA
{ , �' FIN
NCE DEPT.
3 }�'W .I COST OF CONu'INUMON
CON15TR'UCTIONFTE 101 -000 -4118 -tom $2710
Ale
IM3 PRE -PAID ID ka p
$0.0
i
RECEIPT
DATEF s/
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 E Vents
Fireplace P.L. ; Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation 1 Condensate Lines
Party Wall Firewall ,
Exterior Lath
Drywall - Int. Lath
1
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs e�p�
Footings _ _
Bond Beam �� p� �7
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Final _`7
PLUMBING ,APPROVALS
Underground Plbg. Test
Gas Piping
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp Power Pole
UndeLground Conduit
Roug Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)