0102-187 (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
Jf�����
tNbate� n «, ' ��! 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 isnot intended or offered for
sale (Sec. 7044, Business & Professionals Cod'e).
( ) 'I, as owner of the property, am exclusively contracti-g with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&RC. for this reason
Date Signature of Owner
r %I
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
ectidA 3700 of'the Labor Code, for the performance of the work for which this
permi[ is issued. My workers' compensation insurance carrier & policy no. are:
Carrier f� gt�y� l�ryyyg� Policy No.
RITA E 4'3ii.ND �J4V'1VCP"1ii+
(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 p�Visiions of Section 3700 of the Labor
Code, I shall forthwith comply with thosg &s&ons.
Dater?, - f Applicant j+ y~
Warning: Failure to secure Workers' 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 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 ahorize representatives of this City to enter upon
the above-mentioned prope , fiinspection purposes.
Y"
Signature (Owner/Agent)] t_ Date.`
s'
BUILDING PERMIT PERM T# il
DATE-) � VALUATION LOT 0JCt,_ 1V TRACT
r
,t
JOB SITE
APN
ADDRESS
&IL 1150 AX�...riiMA NTLA SC 0
OWNER
-
CONTRACTOR/DESIGNER/EN &NEER r
-
C"OMW. &iM, YHO S
MNTEMPO ROWS
53: a70 A'Vx' WMABERMUDAS
5 U4?0 A'w'. 'WAR10M 0Ab
,1 A QM3TA Off, 92253
L.4. QUOrl.'A CA .9225
(760)564-? 962 MIN 6255
USE OF PERMIT
75 1�V. SIN WRDI?,XTAiL ('W?,' AP%'1N1Q) 7,5L.F.:3" GARDEN
WAAble(.P.Y,"PAl�rft4O -'."IT OTANDARD ONLY
5 P71 W"L 75,00 LF
4 FT. ` IVALY;. 11109 L„4?
.. .,?T°.C:C7'.'�"! COST �ra
2,6.:7
PER. OUT&RA
� f��4 i7` ilv°t'gOAI FEE 101.000-418-000
FEB 2 2 2001
uutw
' 1
MM -TOTAL C lWT1; ?0."1014 AITO I i,.AX ME•C K 1
4..00
r L83B ]I•`RE-FAQ ';3
O
MOO
RECEIPT v[DATE-/
��e�t j (
BYt.•� "s
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.
t=an$ & Controls
Party Wall Insulation
Condon'sate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs ��
Footings O (
POOLS - SPAS
Steel
Electric Bond
Main Drain
Bond Beam
PP A roval to Cover Equipment Location
Underground Electric
Final
_ _
�3 p ( s
Underground Plbg. Test
Gas Piping
PLUMBING PPROVALS
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: