0107-191 (BLDG)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
Date 1-7 t Signature of Contractor
OWNER -BUILDER DECL'ARATI N'
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 3706 of the Labor Code, for the
performance of the work for which this permit is issued.
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 ��55. Apv�,yy. t qp Policy No. 4 [a
dY d:MkS tir �ir4A dy •� 4k4d%f)2�@•Yt�
(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' compensatiort-provisionsi of Section 3700 of the Labor
Code, I shall forth
comply with hose provisions.
Date: 1*7 � Applicant
a ...., .- �..
War'rijng:Failure to secure Workers' ComIlensation 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. kagree 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 proppty-for inspection purposes.
�% 1>3 ari
Signature (Owner/Agent).Date �-
OVA
BUILDING PERMIT PERMIT#
DATE �. VALUATION LOT 0; 07-19% - TRACT
' »a
96.00
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LAOUNaA.ri EI..AP" 110:0,
V&SISR14 ?AONC R00IiWQ -
14011=799
3462 LAC ANA WA Y
RAR-MO.MRAGE, CA 92270
RAW. IRPRWO8 CA 92262
4.293
USE OF PERMIT
07 PII.903I.DIN0a
E's&ROGif o RTC, 10.40 9LI 84630a .P0.1.YUW'l?` HAND FOAM &AC:.R Y'11C
u+/9o-°aTlNG ROOF1140 SYSTEM
REROOF 21906. DO LOCI
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$30.00
C I ( USS PREK-PAIDDFS
w(i.L10
J U L 2 3 2001
I CITY OF LA OUINTA
L FINANCE DEPT
f '
RECEIPT -
DATF_..� v�
PI
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR i OPERATION
DATE
INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck a.% d l 1 Exhaust Fans
O.K. to Wrap F.A.U.
Framing I Compressor
Insulation I Vents
Fireplace P.L. Grills
Fireplace T.O. i Fans & Controls
Party Wall Insulation ; Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
I
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 I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
I Heater Final
W2ter Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sc.wer 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)