0304-352 (BLCK)LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT t►atSAf :3152
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE i VALUATION <� s'% ,'!`�'' LOT v? TRACT
Professionals Code, and my License is in full force and effect. �:; ,) )
License # Lic. Class Exp. Date
Fi4',' �•,<ff�nti ADDRESS t� nl��. �e::,�,ii APN _
Date�'�` Signature of Contractor—L-_ �y, -�--- OWNER CONTRACTOR / DESIGNER / EN (NEER
MICA P1010fil?1R+�?i t. ,���9 J.i ::�11�1 a�.`: � SIM, A.ROMRS
OWNER-BUILDER DECLARATION 81 -260Af AMR, :y,!_2i l Ay E'.1"T 8474
I hereby affirm under penalty of perjury that I am exempt from the Contractor's .1 ,4 OU.DJTA 92;213 IHERIMAl L alk 92M
License Law for the following reason:Si;';�£%•t.'Jnr"r' �"`� ��
( ) 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). USE OF PERMIT
(, ) I, as owner of the property, am exclusively contracting with licensed 01',�1;'1,,1 1aU.U1,ky:(14G
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ,a:.r;•LY.K,14 R 2u,-,) MVU.,iJ ..;:yc.x:44-
() 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: fi 7f, WALL
( ) 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 NATICANA' Id fMON R Policy No. `aV9531C+9
(This section need not be completed if the permit valuation is for $100.00 or less). COMMUCTJOH "M
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 California, and;agree that if I should become I
subject to the workers' compensation provisiogsaof Section 3700 of the Labor �.
Code; �l shall f€ rthwith comply. witF those provisions.
Date: 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, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. Y
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 51m, etYKAYI COMITA.IRLiC, UO)STA' M) RL" C RIS (11K
whose request and for whose benefit work is performed under or pursuant to ,.FAED FEES
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. D[�-J,��t,, ,d;17795 T', ,��
2. Any permit issued as, a result of this application becomes null and void if AL
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. MAY 05 ZOOS' '
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 CITY OF LA QUINTA
construction, and hereby authorize Qeprerlentatives of this City to enter upon FINANCE DEPT.
the above-mentioned property for inpect on purposes.
v
Ji "`�f�. `� RECEIPT DATE r, fes^ BYE _ FI D :TOR
Sigriatu e,'(Own�VAgen�j�',.l.rJ}' f. Dat
i
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
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final -It
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 Pi ing
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: