0106-312 (BLCK)LICENSED CONTRACTOR' DECLARATION
t. 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. Dafen
atell '} " t Signature of Contractor
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.
- ( ) 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-
(This
olicy(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 th�Vfll should become
subject to the workers' compensation provisions of Se t&o 3700 of the Labor
Code. I shall forthwith comply wifh those provisions. • �
Date: x 1 Applicant XI—
.,-�.�•.. ter.
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 Quinti; 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
c listruction, and hereby/ -authorize representatives of this City to -enter upon
e above-mentioned property for inspection purperses.
Signature (Owner/Agent)• a ! Date
BUILDING PERMIT PERM'T#
DATE VALUATION LOT 010&312 TRACT '
JOB SITE APN
ADDRESS
524WO Ait",ENWAVALT..10 773-293.03
OWNER CONTRACTOR / DESIGNER / EN &NEER
A
79-150 C°Arw-LE';E'A 1tIC8 78-1;40 C„AUX,TAWIC0 MMA -230
CA 9225'; 3..h Q1 MTA CA 92253
C760)W-4604 (7BLO 2261
USE OF PERMIT
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Ifitl LF314' F2E'!AIN3MiWA11,0RCO STANDARD
Eb'�f`119; AIM) CC9FT 010 COMM C" TTION 1., 00
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1V'+:•+�4�iT!" UCS# ION d'l -11 g 01-000-41 6-119W WA
n i'R1 SL'QI'C`Y>`AL TLTOWANDPLAY CHRX $371.W
JUN 2 8 2001
CITY OF LA QUINTA
.FINANCE DEPT
PT DATE F BY t ! DATE FINALED INSPECTOR
_ \ .
�i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
?i
Underground Ducts
Forms & Footings
!f
Ducts
Slab Grade
q
Return Air
Steel
i
Combustion Air
Roof Deck
?.
Exhaust Fans
O.K. to Wrap
j?
F.A.W.
Framing
f
Compressor
Insulation
Vents
Fireplace P.L.
1j
Grills
Fireplace T.O.
f
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
it
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
I
Electric Bond
Footings
i
Main Drain
Bond Beam
I
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
;
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
i
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
'I
O.K. for Finish Plaster
Sewer Lateral
q
Pool Cover
Sewer Connection
i;
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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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