0010-139 (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. Classy 1 Exp: Date
k2
Al
�Daie Signature of Contractor v
OWNER -BUILDER DECD ARATIQN_ }
I hereby affirm under penalty of perjury that I•am exempt from the Contractor's
License Law for the following reason:;
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
i.v 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.
(A')` 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 Policy No.
VI"FATE AUNT
(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 p visions of Section 37 q 0 the Labor
Code, I shall fo hwith comply with the a prt vis'o
/Date: ; Applicant'' '� '� °�
Warning: ailurl to secure Workers' Co,�In� ation overage is unlawful and
shall subject an employer to crimina pen a�lfi�' and ciifil fines up to $100,000, in
addition to the cost of compensatio , damages -as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Directorof Building and Safety,
for a permit subject to the conditions and restrictions set forth on his
application. ;n
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. propUrtyfo i spection p � rposeSignature (Owner/Agent)e Date
i i
` BUILDING PERMIT
FERNY#
DATE ..VALUATION LOT
. TRACT
JOB SITE ,
APN
ADDRESS
'
18442 'TAIXING ROC11r, TIM'
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
8201 DW CKPIM3WE FU'a E I
73, 9!6f0 H -W Y '% Z l a i�i�"t 06
.'.
OR 97970.08A'•13
,i�- fii.� DVURT CA 92,260
(7L;iV)368-171 a CUU
6063
USE OF PERMIT ,
0kN AL.T3ULDINC
a.01,YX b' CIARMW WALL . CITY S•6`AN&ARr1
'
y
r,
IRIFI • IT --D COST OF CONYD 'i .U..0K
G'U1 0TRUCTI4 ".1 1 117 -M-416.000
1,723 FR&PAID FM
'T°ilTAL'P=WT FEES DOE PCD'91►'
WORD
RECEIPT
DATE
DATE FIN ED
INSPECTOR
x
INSPECTION RECORD - -
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
' MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
; F.A.U.
Framing
; Compressor
Insulation
t 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
POOLS - SPAS
BLOCKWALL APPROVALS
;steel
Set Backs q l ('
Electric Bond 5
Footings I _ /" 1_/ymoi?//
Main Drain
Bond Beam Z_
/ Z/ IZj�- 1 � o � $"j /L�
;Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final=l.f �p Z_
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
I Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
;
Underground Conduit
I
Rough Wiring
Low Voltage Wiring
j
Fixtures
i
Main Service
Sub Panels
Exterior Receptacles
f
G.F.I.
i
Smoke Detectors
Temp. Use of Power
I
Final
1
Utility Notice (Perm)
I