0208-291 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty.qf perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
U)�
LU Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
LO
LU T-- 4/30/014
40*7599 (1, 27, C3 3 15, FU
7-
cj-I, zil
Z rr' 4t Signature of'Contractor-
0:
OWNER -BUILDER DECLARATION
UJI I hereby affirm under penalty of.perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 1, as owner of the property, or my employees with wages as their sole
71 compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & •Professionals
Code). f
co .1 am exempt under Section —, B&P.C. for this reason
LO
C%J Date Signature of Owner
C) C\J
L) CI) 1 4
WORKER'S COMPENSATION DECLARATION
Z
(r I hereby affirm under penalty of perjury one of the following, declarations:
0 ..(.) I have and will maintain a certificate of consent to self-ins6r6 for workers'
LU Compensation, as provided for by Section 3700 of the Labor Code, for the
< performance of the work for which this permit is issued.
_J
< C) I have and will maintain workers' compensation insurance, as required by
LY, - Section 3700 of the Labor Code, for the performance of the work for which this
in. <
C, ): F-; permit is issued: My workers' compensation insurance carrier & policy no. are:.,
1,ZPolicy No.
Carrier FUMD
(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 l.should become
subject to the workers' compensation provisions of Section 3700,'of the Labor
Code; l shall forthwith comply with those provisio'
.01) 1 Applicant 10 /-
D t"' ' P-7
a e:,
"W / . Y
Warning: Failure to secure Workers' Compensation overage is unlawful and
shall subject an employer to Criminal penalties and civil fines up to $10 ' 0,000, in
addition -to the cost of compensation, damages as provided for in Section 3706
of Ne' 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 appli6aton agrees to, ' & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a r ' esult of this application becomes null and void if
work is not commenced within 100 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 Pity, 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.
Signature (Owner/Agent) -r/Agent) 21;ZIZI Date 7.4
BUILDING PERMITPERMIT#'
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS $ VALIX10JDA
APN
OWNER
CONTRACTOR/DESIGNER/EN INEFR
OUT OFIA QUINUIA,
STM*N RMOLD MOROAM
Is-im Cw"):-s.TeSA&1,C0
64-NMM PAO C01firr FAUA DEMaT
LA QVATA CA, 9225
XAQ1nWT& CA 92251
USE OF PERMIT
PdR.t.dC, COND - AD01 =T, 1410HTS 21 L.P. ?.!j CIAR-13EN WALL;
VAIXIMPTON
2VIM411"M cogr OF CONS-13MIC110TV,
4NMOD
TI'mmawan"
MMIA-MOA1.1 ITS 101-wo-421X000
sm,;n
If,
11( of LAQUINTA
YFINANCEDEPT
`47'11B- 710TAT, C'o
$50.-25
LOSS PRE-&'x,>FM?4'3
TOTAL P9RKfrF=' DOX. ROW,
Y�,
RECEIPT
DATE
BY
CAT7r EINALED
1/
INSPECTOR_
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—
f
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
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)