0309-113 (RPL)LICENSED CONTRACTOR DECLARATION
I h eby affirm under penalty of perjury that I am licensed under provisions of
apter 9 (commencing with Section 7000) of Division 3 of the Business and
fessionals Code, and my License is in full force and effect.
i nse # Lic. Class Exp. Date
(113
I r' r •- `
Date I ' Signature of Contractor
� t
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 .
( ) 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 No.
XMIRA P't
(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 3700ofthe Labor
Code, I shall forthwith comply with those provisions.
Date: } r Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage Is unlawful and
shall subject an employer to criminal pe a ties 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
any permit issued as a result of:this applicaton agrees to, & shall;, indemni D
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc
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 i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives•of this City to enter upon
the above-mentioned property for inspection }purposes. 'i t
Signature (Owner/Agent)i-�'i ��� s�` °'s Date �f' �' t -J
is
BUILDING PERMI1r'.'� PERMIT#
DATE VALUATION LOT 0.-�tr �'� TRACT
JOB SITE * r
APN
ADDRESS..
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1V ATUC W1•S`OtLM
lad i it+�I'd CA 02253
INDIO CA 922101
060)>;¢-403 Ct3ri. s5?'F
USE OF PERMIT
P�JOIESt��•. ��aFaL�:.{v1SlkTitl.i'c3i1EfL° �tl�s:l3d 2iC'rik g'1.�:t;Y.�!' I?�2o:�•i?E�4�S`i'�:k;.
11V2PFA3T1(> . fiQ1Si1�e.,v IDI
X, ANUOil $?A 110S
3 i v3afi 3 ": COW f �'� ��' ? ei ne $3dM �L�T
PLA14 Ch'90f. ME 101 -000-439-319 SWIM
CO WSM.11 '1•.fC". R IFF15: 101,000 -418 -Cal 4,19SX10 `
1P,LXS TRYCAID FEE •• FtryOLz0 000-,. X20-010
1a��1�011+1� 1�4� -- i�t��1L �, 101 tt�J�•�Ei1�0UC; 'ii�;°1,00
+ALMk3'q. M1 CP'l,I.f)NftND 1UNl:T��r
r 'M •�'<:�"� i,i�F
(� jury }
SEP 12 2003:,, 7,<i} T l%l ��A t � t� rr t M21170
CITY 0 LA A
FINANCE DEPT.
r4g0,1QF 42
RECEIPT
DATE r wry
BY -5 r
TE FINALE: '
INSPE TOR
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath r
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
_ ?-
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
/ 3
Equipment Location
Underground Electric
- /�-
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
_/2.
Electric Final
Waste Lines
Heater Final '
'
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
`Pool Cover
Sewer Connection
'Encapsulation
Gas Piping
Gas Test
Appliances
Final
:COMMENTS:
,
i
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)