0107-189 (BLDG)�. LICENSED CONTRACTOR.DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I-_ esChapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O ch License # Lic: Class ;Exp. Date
LO
r_ Of 2"357'!7 C-398
o Z Date "12"1 Signature of ContractorCID
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0.
J U C:) OWNER -BUILDER +DECLARATI a N
HWW r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) 1, 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).
C0 () I am exempt under Section , B&P.C. for this reason
u
N Date Signature of Owner
ON
Q WORKER'S COMPENSATION DECLARATION
00 Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X LLj ILLcompensation, as provided for by Section 3700 of the Labor Code, for the
Oro � Q performance of the work for which this permit is issued.
Q U (�I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
li rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier Policy No.
oo Z) OTAIM PUND t3Q��id? =99
Q (This section need not be completed if the permit valuation is for $100.00Lor 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 CXJif 4nia, and agree that if I should become
1' subject to the workers' compensation provisions-ofaSection 3700 of the Labor
Code, I s all fort'. with comply wit those provisions/
Date: ' 24, 't, Applicant .0 ;t. Q /'
Warning Failure to secure Workers' Compensation cov rage 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 Buijding 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 propertyr inspection purposes. S
A
Signature (Owner/Agent) ��(-^ �"'"" Date )
BUILDI1G PERMIT PERMT#
DATE / / VALUATION LOT TRACT
JOB SITE APN
ADDRESS
48.4214%
p h7 ttv VI[1
OWNER CONTRACTOR / DESIGNER / EN (NEER
110 B.V`d',799 3d 62 IA C1W ANAWAY
RANCHO URMOR CA 92270 PAW, SPRU4438 CA 92261
V60)416 -5g?? 01BIA 2.93
USE OF PERMIT
4�..�RODIV u RTC AC:140 i'MEM(YA - POC,Y7.TRZ(HANX FOAM &,ACAY!1C
00.9f"WO .& OOPI 1(3 ISYS TNI
"I-ROOP
3',, "s 001.1
X31nVLTAV 11,1097.1 UP COIN91NUC01110111
WEROOF nE 1 X91.000^418h{i O $140.00
WKS
FM DUE NOW
DATE FINALED
X30.00
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
I Compressor
Insulation
; Vents
Fireplace P.L.
Grills
Fireplace T.O.
i Fans & Controls
Party Wall Insulation
i Condensate Lines
Party Wall Firewall
j
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
:?lumbing 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
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)