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LICENSED CONTRACTOR DECLARATION
I.tiereby affirm under penalty of perjury that I am licensed under provisions of,
Chapter 9 (commencing with Section 7000) of Division 3 of,46'Business and
Professionals Code, and my License is in full'force and effect.
License # Lic. Class zp. Date
74 11 13 Cc ` 0 i 11/:30/02
�Daie Si U, of Contractor / It tAA
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OWNER -BUILDER DECLARATION �l
I hereby affirm under penalty of perjury that I am exempt f� m the Contractor's
License Law for the following reason: `
( ) I, as owner of the property, or my empl yees 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
�;rformance 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 0MATRFUND Policy No. I` 7015-09 '
(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 whichathisf permit is issued,
I shall not employ any person in any manner so as twbecome subject to the
workers' co tion laws of California, and �tgree,`tjtai if should become
subject to tHe, vog�Cers' compensation brovisions of Section 3700 of the Labor
Warning: Failure to secure Workers' Compensation `Ebverage is gnlawful 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 aft r ey'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 statei,that the above information is
correct. I agree to comply with all City, and fSt�te I Vvs relating to the building
construction, and hereby authorize representpitivesIof this City to enter upon
the above-mentioned propearty for inspec io urpose
Signature (Owner/Agent) \'v
t' (date 11-4
BUILDINGTERMIT PERMIT# '
1 ,
DATE VALUATION LOT TRACTf
JOB SITE
ADDRESS 51 -ZQQ AVEP, IDA DW
APN
OWNER
CONTRACTOR /DESIGNER / EN (NEER
P.O. ACDF 11335
45.260 PAW. Vii'.
FA1MDMoX CA 92255
"W3I0 CA 92201
(760Y347-8913 C DL, # 4998
USE OF PERMIT
P001, AND/OR tikA
POOI.l A ALAI &IZ;I'BAR.F'.3L-tS Sk1,A.},'L FF,114 PL AC r,—A'.•' .PRF.?,PL.aQ.;TER
i1<fSPEC110-4. EQiilPlalEkiT z?NCW13ilU ih OT INC'-Ltkl. ED
P001, At3WCy,R SAA NAOMI LS
.IRI COST Off' i;NC3�+S"TRUC 71014
14,E X1,00
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PLAN CHECK FEE 101.000-439.318 $99.41
C."ONSTR.UC ION FYZ 101-000,419.000 2153.00
IACPANICA1.T8—13CL 1101-000-421-000 $21,00
F.1,Y,C7I2tt di.L FELE - POOL 'Al 000-420-000 $45.00
PLf,IMBNO M-- POOL ' -00%0-4 ', �0£1
DEC 0 4 2001
CITY OF LA QUINTA
FINANCE DEPT.
.4UB-`I'MAL. C014MRiSM1014 AND FITA 4' Ci�'.G'i
$348.45
IAMB :!'REr3EATD1711' `'
$0,00
(RECEIPT
DATE
BYD
NT
INSPE T
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
_
Final _
Underground Electric_
Underground Plbg. Test
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
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)
COMMENTS:
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