0105-122 (BLCK)LICENSED CONTRACTOR DECLARATION,.t
I hereby affirm under penalty of perjury that I,am licensed under provisions of
Charter 9 (commencing with Section 7000) of;'Division 3 of the Business and
"'Professionals Code, and my License is in full farce and effect.
License # Lic. Class �+ 1 Exp. Date
• • 23012 'B HIC ° j i �' ���� I W
Date Signature of Contractor # A
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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, amexclusively 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.
, �0) 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.
(This section need not. be completed if the permit valuation is for $100.00 or less):
O 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 Califor6ia, and agree, that if I should become
subject;to;the. workers' compensation provisions"`of Section 3700 of the Labor
Code, I shall forthwith comply withthose provlsl ns.
Date: Applicant t r % �'lA
-'"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. Inspection purpo'ses:- Bt%
Signature(Owner/Agent) l r"j _ Date
SUILDINGPERMIT -PERMIT# ;
DATE VALUATION - LOT ID�Qt �kR ' TRACT j
O'.'.492 t"1
JOB SITE
APN
ADDRESS
53 -US TROONtRAM
7704"-M
OWNER
CONTRACTOR/DESIGNER/ENGINEER
: r0IA XiGL i
I3EMM, CONS1'RU- iiL;9
y 7t n
48221 FAMED CANYON ROAD
; + .ElMON Cry. 90853
PAILM D -MP C. C& 92.260
(76gfl? 4764 CLIA 1430
USE OF PERMIT r, -
130 LF COMBO ;F?MA1141HOtf4M.A,RDEN WAU, PER
OPRWRE(DIONORM 9TRUCTUMLCAWNF4i,.. INS
f
f rf, WALL S:y9),Qb U
I&MMMID COST OF COASMUMON1
CONST1tllt ITION 103 44041€ -0035
AND PLAN C RECK
$,63,00
r
r ERWI mms DUE now
MAY - 9 2001
CITY OF LA OUINTA
FINANCE DEP
RECEIPT {' BY
DATE FINALEFINALEQ.
INSPECTOR
r
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
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
Std
Set Backs
Footings
Bond Beam
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Final 1p ' % O7/
Underground Plbg. Test
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
COMMENTS:
��U'�l �-�,,,,���e.,..� �.✓���
F r5 % -Z U
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior ReceRtacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
8JOB. NO. 25� (01 Zt
4OF;NSON AND NIELSEN ASSOCIATES
Lo 7g) �R 660 By J
.CONSULTING STRUCTURAL ENGINEERS
647 N. MAIN STREET; SUITE 4-13
L ja (� V ItJt CA DATE
RIVERSIDE, CALIFORNIA 92501
909-686-5122 FAX 909-686-6752
COLOM�I 3SH I OF
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,CITY OF, LA QUID T
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BUILDING .& SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
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