0310-025 (BLCK)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
gate �^ Signature of Contractor
r
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
1
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 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 r%A°1'L FuigD Policy No. 220_ 0019787-2002
(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 provisions of Section 3700 of the Labor
Code I shall forthwith comply with thoserrovisibfns.
.Date: + Applicantii 1-�!r'
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 City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property forinspection purposes.
Signature (Owner/Agent) /'!1_1 -�,y -� � Date ,
` BUILDING PERMIT PERM'
DATE10AWIM VALUATION �;g LOT' 12 TRACT
JOB SITE
ADDRESS 7'i420 CALL E �I'YMCULA
APN .774-2424M2
OWNER
CONTRACTOR/DESIGNER/EN (NEER
THOMAS BIDIW
DAVID 1;.. AtJDlidGWT N
F'.0, BOX 134
41-790 FUM'WrAGE DR
LAQU MTA CA 92259
1Bh-TJM�ixPums CA 92201
(760>409.7528 LSI. t 3124
USE OF PERMIT
GENnAL $TTLDING
'150 LFCOMBO P I ETAAINiR+ O WITH S' O"DEN W:ALls &1501AP 6'
GARDEN WAL1,01TY's1ANPARD..
6 FVWALL 300.00 LF
ESTWAIND COff OF COMM'HUsnMON
C014STRUCTIO14 FEL 101-000.418.000 ��►,�0
".p . ' W . TC'1 OAi AND PY-,. t MIC'£C
Sf9.aa
p LEM PRE -PAID F
.$0.00
OCT 0 2 20� 1x.WIT'4 S Dum-Now
CITY OF LA QUINTA
FINANCE DEPT.
-
RECEIPT
DATE/BY
v�
BY �/
�.,._,._.._-
DTE FINALED
INSPECTOR
...
�.
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
OX to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Appliances
mnin
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
t-
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
Fans & Controls
Final
POOLS - SPAS
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underaround Electric
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for. Finish Plaster
Pool Cover
Encapsulation
Final
=COMMENTS:
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