0306-515 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
f— 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.
C) ch License # Lic. Class Exp. Date
r- Q In
W
Z r— Date Signature of Contractor
0
cD O �
J U � OWNER -BUILDER DECLARATION
W WW r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
I) License Law for the following reason:
Z_ (y)" 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 excl�vely contract) g with licensed
contractors to construct the p=B&P.C.
. 7044, Business & Pfessionals
Code). 1�� s
ce) () I am exem�t under Section. fo-r1this r ason—
N Date _ � 5Signature of Owner
OUrn yN..VI
CL Z WORKER'S COMPENSATION DECLARATION
ON
2 Z I hereby affirm under penalty of perjury one,QWde following declarations:
LO <1-2 p () 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
m� Q performance of the work for which this permit is issued.
Q C) ( ) 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 L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
ob 5
n C)
J (This section need not be completed if the permit valuation is for $100.00 or less).
( 0-1 certify that in the performance of the work for whi5�this-p&rmit is issued,
I shall not employ any, person many man er so as 00 become' a+ subject to the
workers' compensation laws of California, a d agree that if I�should become
_ subject to the workers' compensation provisi ns of�Sections3700 of the Labor
Code, sh Il forjhwith complywith tt ds'e prov(Sions.`` Section
/ Date: �' e "" Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal p gnalties and civil fines up to $100,000, in
addition:to the cost of compensat of amages 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 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 sand State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pkoperty for ' speetio purposes
Signature (Owner/Agent)�� Date%�ales�
fi
BUILDING PERMIT PERMIT"
()�fffi-SAS
DATE 06malVALUATION •� LOT: ry TRACT
oc
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
JAMES KWIMIN1M0M.
-7,9.275 D&WT gfREAM � 8
LA QUDTrA CA -2253
USE OF PERMIT
PLUMBING
QAS LXNE FOR COWNEC1 IOW TO FUTURE APPROVED APPLS.ANCF
VALUATIOI4 Is
ESTYtEtiAIND COW OF C;o1'7gr1dUCTi10N
PERMTKE SMVNARY
PLU103140'ME 101.000419.00 }-
S
SUB "Tor m, i3i,`.i:f i7e"TIMT AND PL AX CHEM,"
$18.00
e - LMS PRE -PAM F1.'14
$0,00
:AL P30CEW "Es D''UX NOW
$18.00
-.2003.
JUIV 3 o-.20 03.
CITY OF LA QUiNTA
FINANCE DEPT. :.
RECEIPT
DATE ,f� f/ „y
BY
IN
SPECTOR
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 8 Controls
Party Wall insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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:
jt
1'
s
Final.
Utility Notice (Gas)
ELECTRICAL APPROVAL
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)