0110-294 (RR)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 afnd effect.
License # Lic. Class Exp. Date
6?1�i`rfi� t`r r It61t
Date 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'
compe.n9idlion, as provided for by Section 3700 of the Labor Code, for the
pe o'rmkryce of the work for which this permit is issued.
n 1I 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 B' ATIT.1it111,1D Policy No. 161 31,6.01
(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 ch this permit issued,
I shall not employ any person in any manner so art becom6'Zu Z%to the
workers' compensation laws of California, & d, a eellthat if I should become
subject to the�worker§%compensat', pr�v�lsioris,,, !� ection 3700.of-tiie Labor
--,.Warning-: Fallu a to secure Workers' Coensation 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 fo"r 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 andstatethat the above Information Is
correct. I agree to comply wlth ��l1-Clty,. ar�Q'State laws relating to the building
construction, and hereby•auth 'fize `rpre'sentatives of this City to enter upon
rty,
the above-mentioned pro ,_
or inspesytlon,purposes tr
31 Ilalwe Ownel/A.., Dale
WI X111 I �_
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BUILDING PERMIT
DATE i unw VALUATION s4amm LOT
JOB SITE
ADDRESS 0 AVX A7AM VALLEJO
OW C JORNWR
33-430 AAVAUJO
Lt. QUWrA CA 92M
USE
/OF�PpER�1M PERMIT
BUD-DING
A ISH
PERMIT#
M 144V
TRACT
APN
CONTRACTOR/DESIGNER/EN (NEER
900FIRZ SPEMM Y
•14-"0 RUSAb` Vra.`f BAY DR.
l; P%iiJ�3A 1) CA 92211
f,-/60)200?,0811 C",BX sfa 1420
XZROOF t,230.00 Le
K
1
R611`111I ,'M)187 car:, COMMUC ON 4.230,00
VIM WINSERMWARY
REROOF 1E : 130,00
=OC�129
K%�W5U, CCASTSMIXTION AM IP W4 dMM $30.00
Lim"! .-PAliJnaz $0,00
RECEIPT DATE /�/ BY DATE FINALED 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
' r
Final
/L�3�� t
Final
POOLS - SPAS
BLOCKWALL
API�ROVALS
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)