0401-332 (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. Classy� ',+ Exp. Date
64390 'C39 al / r 07/3112f
Date 1 f ��'. T % tSignature 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.
(i�) 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:
Carrior STATS FM . Polioy No. 286 01 000763
(This section need not be completed if
( ) I certify that in the performance)
I shall not employ any person in an}
workerscompensation laws of Calif
subject to the workers' compensatior
Code, I;'shall;forthwith/comply wkth,th(
D ate" '/ 11Y v /Applil�,t • //l,
he permit valuation is for $100.00 or less).
f the work for which this permit is issued,
manner so as to become subject to the
rnia, and agree that if I should become
provisions of Section 3700 of the Labor
;e provisions.
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 Gity, and State laws relating to the building
construction, and hereby auth, orize t representatives of this City to enter upon
the above-mentioned property'for'inspection purposes.
/Signature (Owner/Agent)! 11 �� Datet
BUILDING PERMIT PERMIT#
Oft-'s<1�2/20C
VALUATION �� �� LOT TRACT
DATE 01 l2�
JOB SITE ADDRESS '& 3%1 + ,S1NG1PT 'l� MUMS r.J� YE'
APN _
OWNER
CONTRACTOR/DESIGNER/EN (NEER
VT 'MR PROM
WAYNE R00MG
7 8-395 95 :r'IAdC'rYNG ,"At M
P, 0. BOX i 155
LA QIMITA CA 9225:3
PALM DESE`1IT CA. 92261
C760)i72.2151 G' R, 4877
USE OF PERMIT
GINI ZA1r.. IMWI.i< G
fZE-11, 0F'WITH 3D '4`k Mf TJMF.f.NRi.,HgY, GC;MP. SHfN0LZS
F9'r' LUATIO14 W
o°:£PFl➢"�2:,r�'IPi,
MUM M "MAR
RRROOF FE 101-000.418-000 130,00
J Q
JAN 2 6 2004
CITY OF LA OWNTA
FINANCE DEPT.
ST.I'B 170TAL COM UCT1011 AND PIAN CJ.CK
$30.00
MEW PRE-PAU7 FRES
$0.00
1VTAL:MT1l D :fit 965 DUE NOVY
M.00
I
r,
RECEIPT
DATE r
BYr DAT IN
SPEC
u
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
_
Steel_
Roof Deck ,�
Combustion Air
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 _
BLOC KWALL ROVALSO
POOLS - SPAS
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
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: