0401-136 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of, perjury that 1 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 760335 B V3)/05
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).
( ) 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.
JVJ 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 STATM FU14D Policy No. 1600301-2003
(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 provisionprof Section 3700 of the Labor
Code, I`shall, forthwith comply with those pJp vlsrons -_%,
.Dater O ` Applicant _ A yt
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. I.
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.
BUILDING PERMIT PERMIT#
040a
DATE VALUATION LOT TRACT
/f C % $2 v100
JOB SITE APN
ADDRESS 57645 S7'�LMPOLIE: DM.'VT
OWNER CONTRACTOR/DESIGNER/EN (NEER
CRV GOLF VE13TEMIROOK DEIV LOPISiN`:E COWAWY
5 14 0.AMI PD. AINC. DW 5140 AMIDA WCWAS,
C.A•R,��`:I AD CA 92008 +CA BAD (A. 92008
(760)8O4-6868 CIYLN 3376
USE OF PERMIT
112 L. F. 6- BLOCK WPZt.L; CITY STANDARD
6 FT. WALL
112.00 LF
'xiCI"' 7 ? {:ii1T9' OF C:UMMT1C.0I10L; 2=00
CONS':f'R'JC T EOIN TEE 101-000-4118-000 $54.00
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, inspection purposes.
RECEIPT
Signature (Owner/Agent)' Date
CITY OF LA OUINTA.
SM -T07 AL C01191T'.LfiG''7,ION AW1. PIJW MMI "1C $54.00
IMS MR -PAID IMS 3 $0.00
79LU, PEW -10M MIN DUE NOW 1 $54=
id: I BY /✓ f / 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 4
1 Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING PPROVALS
Gas Test
Electric Final
Waste Lines
I Heater Final
Water Piping
1 Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Waster
Sewer Lateral
i Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)