0212-094 (RPL)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
614611 C53 3131103
Date>� " Si nature of Contractor
._ - — - _ .
4 -140
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
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.
�(,t) 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:.
Cartier i8'd'•A'#'F MID Policy No. €34510.46792
(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 provisions.
Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition -to the cost of compensation, danmages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for: a permit subject to the conditions and restrictions. set forth on his
application.
1. Each person upon whose behalf this application is made & each.person at
whose request and for whose benefit work is. performed under or pursuant to
any permit'issued as a result of this applicaton agrees to, & shall ,tindemnify
& hold harmless the City of La Quinta, its officers, agents and employees..
2:'Any permit issued as a result of this application becomes null and void.if
work is not commenced within 180 days from date of issuance of such '
permit, or cessation of work for 180 days will subject permit to cancellation..•
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Sig nature (Owner/Agen>,-0 � �� Date, ' ""l X4r,.,._�-
:" s'JI:�_i IN_ G PERMIT PERMITs�
DATE- VALUATION LOT TRACT
JOB SITE r'
ADDRESS.: "40-24 'VATMiC1A C01M
APN
,OWNER
CONTRACTOR/DESIGNER/ENGINEER
01MC1AT'.�,TR)i IJ, INC
M01 1yr{£t1rPt; 01A &04148
77-5&1 C'r9CW.RY 4XUB DIRWla €31JIMP 131
_ P.0, BOY, 1. 91....
PAIXI DES7:� T CA 92.211
LA QUit3 VA CA 512253 ° • -
USE OF PERMIT
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POO1,r.F1NDIOR SP;A 1Pkf?>S$!: 14
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PLAN clirC1k". WE 101 -M -439-M �:lSl4`.3Q
P'OHa'!'ftliCITI9J.1<! 8-000 •E6"L.UtI
'fvlEi;ki WCAL 179E .- POOL 101.000.421.000 HIAA
FUE — P003L"-_ 101-000-42,0-000
PLUMBING k"ER -- P001I SZU0
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.3 DEC 2,0 2002
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CITY 0F LA QUINTA
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RECEIPT ,'
DATE }{
BY
DATE FINALED
INSPECTOR r
yl.,
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
r r
Bond Beam
Approval to Cover
r
Equipment Location
Underground Electric
f
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
Appliances
Final
g
Final
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
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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