0210-090 (MISC)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
748004 B � r� 4440102
111]ate IA -11) in't Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I-amIexempt 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.
J( ) 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 LMITED PACIFIC INS Policy No. • WWAI 19180.00
(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
Conde, I shall forthwith comply with those provisions.
Aate: Applicant
j�
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 for ins�ection purposes.
.Signature (Owner/Agent) " Date L %4.. j ) M -\
BUILDING PERMIT PERMIT#
��,104M
DATE VALUATION LOT TRACT
101 84r; �3,tJC�.ilt3 3S 29,447
JOB SITE
ADDRESS • l945 W,. R==, RYk WAY
APN
-767-M-040
OWNER
CONTRACTOR / DESIGNER / ENGINEER
STEi7:1+ T WA�� 140MES
a'i'x'i,'JF Wfil3.:- HOMES
7161 .00IMA AVR,
7161 .tNDI.MAAVE,
(909)7M-0840 MR, .5'351
USE OF PERMIT
1vFi►iC7'I-LANWUS
x
SPWIAL INS"M.TIt. N TO FINAL S.i D (FF.'XPI ETY HP. -MIT 0006.299)
O .
0
VALUATION 10.00 Lq
CITY OF LA QUINTA
FINANCE DEPT.
merm, AT I) cont 0, P. CGInsfir'i71,'"1 oN
10MDD .
M AL INSPECT1011 101.000.423-000 $100,00
SUB -TOTAL AL CO-NIwMIJCa"!°. JIT AND PLAIT MTECR
$100.00
1Y."M PRYI-PAMY "D
$0.09
RECEIPT
DATE
W i-2
BY
kP
DATE FINALED
INSPECTOR
- t
—'Z
INSPECTION RECORD
- OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines a
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Undercaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
TemD. Use of Power
Final
Utility Notice
Final Ii
Final
BLOCKWALL APPROVALS
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
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
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Undercaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
TemD. Use of Power
Final
Utility Notice