0103-146 (TT)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 Ekp. Date
Date ^Yrs f' Signature of Contractor,
/
OWNER-BUILDER D_CLIA TION
/
I hereby affirm under penalty of perjury that I arm 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 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.
laTA17F. KIND 1542996.00
(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
Code; I shall forthwith comply with those provision .
Date:t-- Applicants �: r., r
i l Ir�r✓•�v
Warn ng: Fa lure to secure Worke s' Cd}mpensatlon coverage is unlawful and
shall subject n employer to crimiwr�aI penal it.,
and civil fines up to $100,000, in
addition to the cost of compensati n, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. i
2. Any permit issued as a result of this application becomes null and void*. ,\
work is not commenced within 180 days from date of issuance of such
" permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
,the above-mentioned property for inspection purposes.
t P
Signature (Owner/AdejhQJw^r� ! ,. D t r
V4, R *J s r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01(X$,146 TRACT
atl.�l:t(D.��7f' t..-,• ; ��� '� D£D d�D ..� 2R47lD»
JOB SITE
ADDRESS
AP N
8-5-91 �"�'C.Il�G �d�D�" K 1'0T?1q
OWNER
CONTRACTOR / DESIGNER / EN (NEER
MUM= FwPiNcrML 1.1c
MUT CONMRTICTION
$205 CrRKMI E M
W$ m 961DEWT 1 13 NIM itfi
W— A.VER..'row CSR' 97008
PAU4 D lmir ' %CA 92260
(760)568.1712 CSW
USE OF PERMIT
C.014STP,UC:TION TR.AUM PSR MUP 2000•222 C:OatPWANCtl:'° in H ALL
FI:r•#t.AL &S`I`ATE LAW, CLUDING'FE, ENDANGERED SPECIVS ACT
OF 102 (16 UX.C. § 1531, ZT 39Q.) If 1APPI.ICAt3i.RY IS
VALUATION 1129a.09 LZ
Y>TMATM CONT OF' C'OMMU(Mt. N
1409.00
PY-QWr FEZ &VADJ RY
TI?MP-Ct.!NSTRUCTION `rWisiA 101.000-423.000 NMOO
1
'S� P
91 ms, Kt;h:�l�la'i�?�U A I�CD�3 KND PLM CHECK
J
'$200.00
L31193 PRF,,-PAXD F'f.
$0,00
, i
0 2001 T AJjFe
MAR diYP1310DUE NOW
2 .
S2,M)DO
RECEIPT
DATEJ
BY k
DA D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
s 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
Vents
Fireplace P.L.
Grills
Fireplace T.O.
j Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
CK 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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final /
Utility Notice (Perm) I�
COMMENTS: