0308-137 (BLCK)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) ch License # rfa Lic. Class Exp. Dattel
CY LO
3 1/04
LLJ
o Z r --Date � � � � L, -Signature of Contractor
J U C! OWNER -BUILDER DECLARATION
LU W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ d License Law for the following reason:
Z ( ) 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).
LO
( ) I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
ON
Cl)
Li Q WORKER'S COMPENSATION DECLARATION
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
C0 Q U () I have and will maintain workers' compensation insurance, as required by
O C) Q Section 3700 of the Labor Code, for the performance of the work for which this
ti rn H permit is issued. My workers' .compensation insurance carrier & policy no. are:
N11 Carrier NATIONAL, U1091N X Policy No. Yit2530
ob 5
O
J (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
3 subject to?the workers' comperisation'provisions of Section 3700'of the Labor
Code,,lgshSall•fortHwith complyrwith those provisions.
Date: !! 1 4 - : io"Applicant �`; l L.:.�A- ^•
1111111 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
b 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 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 and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representative's of this City to enter upon
the above-mentioned property..for inspection purposes.
Signature (Owner/Agent) r ��li y .wL.. .^« Date . } i�`;s
• it
BUILDING PERMIT PERMITM8 43 j
DATE VALUATION iii "'�' LOT TRACT
-a
JOB SITE g� PAINI� �• , ]DiUVE APN
ADDRESS PAIN
IM,
CONTRACTOR /'[DXESIIGNNER / EN INEER
�'��i4Rf..l3.t•, J.AJ.W�:rL9 /,7,x"]S: r'11:4�i.�1TlJ,�."sv
81 ^200 AM"ITOB 0 P�1 d`rU P.V AfLz f 7,
1AQUINTA. CA Ldls„?%l1Tt A CA 92863
(909)833-9996 03710 68';1
USE OF PERMIT
ORCO 8fleff IA
4 in, MALL 147.00 LF
4 FT. 'WA.0 147A i,y
Ir OF l.•OMM. F...l3OI
COVIeY"TfiAICI! 6:' ,P-1 Y 1 ': .- I S49
6, 0 rl 7,0D
W l.r•Y "'�. �..J g.d":.Si.. w��.JAy o1 i. ��} :F L+3J. dV :11.Y &1 PUY 1..["iA". $90,00
RECEIPT DATE BY
cf f. ".k
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wali Firewall
Exterior Lath
r)ruvmll _ Int 1 nth
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam 17
OPERATION I DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans 8 Controls
Condensate Lines
Final
POOLS - SPAS
Steel
Electric Bond
Main Drain
Approval to Cover
EauiDment Location
Final i 1 6
Gas Piping
PLUMBIN A PROVALS
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
Final
COMMENTS:.
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Condult
Rough Wiring
Low Voltage Wiring
Fixtures /
Main Service 1
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)