0107-198 (BLDG)LICENSED CONTRACTOR DECLARATIONy
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
57� C,39 � �• b1f31t2C
Dated' t + Signature of Contractor
—"--"z-'(jW- tk--BU1'L"DER'-DECLARATI N
I hereby affirm under penalty of perjury that I am er:-jmpt 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.
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.
SUFF, WAD 04 24-s9
(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' compenpti( to provisioq,§IofTSection 3700 of the Labor
Code, I shall forthwith comply with those profisions.
Applicant-
Warn
pplicant
Warnin,,.g:�FaiIurfe o secure Workers' ComIensation c verage is unlawful and
shall subject an employer to criminal penalti s and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his.-.
application.�-
1. Each person upon whose behalf this application is made & each person
whose request and for whose benefit work is performed under or pursuant to r 1
any permit issued as a result of.this applicaton agrees to, & shall, indemnify � . +,
& hold harmless the City of La Quinta, its officers, agents and employee's! t
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of sucl
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above informationlL
correct. I agree to comply with all City, and State laws relating to the buildir)g
construction, and hereby authorize representatives of this City to enter upo!=
the above-mentioned proms foqr inspeetrib-h purposes. 1
Signature (Owner/Agent);_ Date's
BUILDING PERMIT PERMIT#
DATE l `VALUATION LOT 0107,.499 TRACT
S31 M IOU
JOB SITE f" ` - APN
ADDRESS
48-143
CALIX
yy pvX �'ry Ryypp
OWNER CONTRACTOR / DESIGNER / EN INEEFI
PG 1~ OX °x"99 346. LA CfOCAARAe WW
RAM010 MR0.0E CA 92X?O PALM V"08 CA 92262
(761*416,4077 CRU, P 4293
USE OF PERMIT
RX 11001`- RTC IC130 4MR40A a !°0L'P iRri-f$ANE FDAH &ACKMICI
Ct*3l?, ,I FO H1,0 'J.T4NO S`ifMTNI
REfOOF
:k:A810D La
p y�, . Q� yy�, y�1 ��gq�� �g.RVIVIAM,� MSM OF CONSM 'C-1500
PIMAUT Al..19 M'.7a'.34FYd4fAYC7I
REROOF ME 101-000.418„000 SX00
$,30.00
SM 00
V L L"J LI� ` AVB' ip• .4 .f�i.T.lV.'`��..� FEES DXT11MO
F'l 4A
RECEIPT DATEBY DATE FINALED INSPECTOR
122,31Z
. /
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck q_lj. 0 S7
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 _/
BLOCKWALL ,APPROVALS
Final
POOLS - SPAS
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
t;Vaste 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
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)