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LICENSED CONTRACTOR DECLARATION-
hereby affirm under penalty of perjury that I am licensed under provisions'of•
Chapter 9 (commencing with Section 7000) of Division 3 of the Bus nd
Professionals Code, and my License is in full force and effect. —
License # Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION / —
I hereby affirm -under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: `
1, 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 f jth licensed
contractors to construct the project (Sec. 7044, Business',84, Professionals
Code).
() I am exempt under Section , B&P.C. for thisfreason
Date r , -'e') ..'''Signature of Owner
� y .. .mow......-�..w
WORKER'S CO
RATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self-insure•f6�r 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•r"equired by'
Section 3700.of the Labor Code, for the performance of the work for which this,j
permit is issued. My workers' compensation insurance carrier & policy no. are:,
Carrier Policy No.
(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 3700 of the Labo
Code, I shall forthwith comply with those provisions.
-Date: ^.' ,Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful an
shall subject an employer to criminal penalties and civil fines up to $100,000, i
addition to the cost of compensation, damages as provided for in Section 3708
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safetyl
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 representatives of this City to enter upon.
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) _ � .. r':r"- - ,�"^ r Date•,r
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LDING PEf� �-�-- PEFIMITN+•""'----r-
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DATE VALUATION , �5? _ ._,. {�Q_2 TRACT
JOB SITE
APN
ADDRESS
.V-990 A��• qM
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PRE'UDY TT & YA91RA E C,f WEA.
B7iiME:F>?
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USE OF PERMIT!
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90 LP 6' GA;ii3 EN YVALL
38 UP 3' QARDEN IRKA.%L
ALJ, CITY V FARO RT)
b FT,. W Fi:M + 50.00 LF
5 ! :' A ,L �A 00 111
CO]AMY RUCTt.ON PEI 101. -000-418-00°'o $63.00
JUN 2 0 2001
CITY OF LA QUINTA
FINANCE DEPT
77-
,9TJB"¢dFJ.A1.., 00.lSCT.lC L01 AND M1+.Ti.Ch.M.l.f
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RECEIPT
DAT"
BY
DAJE FINALED
INSPE OR
i�
, `
INSPECTION RECORD • "
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
,
Set Backs
, ,
Underground Ducts
Forms & Footings
-
Ducts j
Slab Grade
Return Air i
Steel
Combustion Air I
Roof Deck
Exhaust Fans ;
O.K. to Wrap
F.A.U. j
Framing
Compressor ;
Insulation
Vents 1,
Fireplace P.L.
Grills I
Fireplace T.O.
Fans & Controls I
Party Wali Insulation
Condensate Lines
Party Wall Firewall
f
Exterior Lath
i-
`
Drywall - Int. Lath
i
t
I
Final
Final
- BLOCKWALL APPROVALS
_
Backs 1_�rTS_` O t ��
t lings _ l
mAd Beam (G�s'bZ ST
I POOLS -SPAS
steel I
Electric Bond
Main Drain {
Approval to Cover
Equipment Location
"
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shouter Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
;Appliances
t.
7,Temp.
U4 Notice (Gas)
ELECTRICAL APPROVALS
Power Pole
Low Voltage Wiring
Futures
Main Service
Sub Panels
`7 Exterior Receptacles
G.F.I.
• Smoke Detectors
1 Temp. Use of Power
t
Final
Utility Notice (Perm)
,
Gas Test I
Electric Final i
Heater Final I
Plumbing Final I
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover I
Final I
COMMENTS:
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