0310-017 (BLCK)LICENSED CONTRACTOR DECLARATION
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
C'4 W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
LO
w 640934 B 03/3112C
Z r.- Date Signature of Contractor
—
0
J U OWNER -BUILDER DECLARATION
W WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
t'') () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
Q WORKER'S COMPENSATION DECLARATION
o Z I hereby affirm under penalty of perjury one of the following declarations:
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
0� Q performance of the work for which this permit is issued.
co I have and will maintain workers' compensation insurance, as required by
Ci U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il 0) Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carver NATIONAL UNION K Policy No. W63$33
��
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 agreerthat if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code I shall forthwith comply with those provisions
Datel L7 ! -� L 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
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 authorizerepresentatives of this City to enter upon
the above-mentioned property for irispection purposes. `
Signature (Owner/Agent) Date—1
/tel �~ter
BUILDING PERMIT PERMITN
W10.0! 7
DATE VALUATION S4J 75M LOT 50 TRACT 50023
JOB SITE
ADDRESS 6if t3�I T}>l►Jjh # t a5` Ail � 0
APN
_
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
&F-A.HOI IM
S%MA.HOMM
81.260 AVFWH 62
€11.260 AVENUE 62
LA QUINTA CA 92883
LA QMNTA CA 92819 t
(909)833.8995 CBuf 6876
USE OF PERMIT
GF140ALBUILDING
135 1.1t, 6' O"VrX WALL, *50 L.1* T RKTAININQ WAIL4 BOTH
ORCO SYSTEM
6 PT. WALL 133,001.E
4 ET. WALL. 30.00 Lt7
:85'T'.tIV ATYM COST OF CONS'T'.1�!jIMON
4,1.7&W
..PkTt1'r r FEN SUMMARY
CONSTRUCTION 'EE 101.000.416.000 S7'2104
OCT 2 3 1003
dTY �!�!, �1lAWXA
MM-TOTAY., CONST (ULMON ANS PLW CMI=
$72.00
LE.M PRE -PAD) 1,W.3
T-O.QO
IW11L PFfair ' Ilii DUE NOW
$7:2100
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
ri
r INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE --TINS
PECTOR
• BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
'
Drywall -Int. Lath
I
Final
Final
BLOCKWALL APPROVALS
steel
POOLS-SPAS
.I
Set Backs
Electric Bond
Footings
Main Drain,
Bond Beam
Approval to Cover
(Perm)
•
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUM BIN(3( APPROVALS
Gas Test
Electric Final
-Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
+.
Shower Pans
O.iC for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test _
1
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
`COMMENTS:
_
•
I
3
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a
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(Perm)