0110-205 (BLCK)F�
LICENSED CONTRACTOR DECLARATION
'T,hereby affirm uAnder penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
4399(9 0 10 ao
•Dated ° �
—Signature of Contractor,, �` "";'-ft' f'
OWNER -BUILDER DECJ.,ARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 Cgde).
( ) 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
performance 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�.fsk zed.%,%l orkers' compensation insurance � � d -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
worker compensation laws of California, and agree that if I should become
su iect to the workers' compensation pr visions��f Section 3700 of the Labor
de, 1,s hall forthwith comply with tho� 6nsr'
J�'" "d Applicant—
y , y ""-7
Date: • Applicant W_
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
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 1 have, read this application and state that the above information is
correct.'t:agree to; comply with all City, and State laws relating to the building
r:=
construction;< and Hereby authorize representatives of this City to enter upon
the a ove-mentioned property !9r-1nspectjorrpurposes..
%Si nature 'Owner/4'> Date'/
BUILDING PERMIT PERMITN
DATE r) ler
VALUATION sq� oo LOT TRACT
b
1 JJB
SITE
ADD ESS J� :� �%l9l.
APN
OWNER CONTRACTOR / DESIGNER / EN (NEER
54-510 AMID ,1;t 82.231 EWTHlLTO CT,
QU19M. C.0% 92253 =10 CA 92201
(160)347.0399 cWt 3225
USE OF P MIT ,
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C'ONTR Ude;` 10.14, Yge 101-000.4 ,18-•000 WAD
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NOV 27 2001
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$41.25
1XYrAL:FT,RMTV FM DUE NOW
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RECEIPT
DTE .BY
DATE FINALED
INSPECTO�n
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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 & Controls
Party Wall Insulation
Condensate- Lines '
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BI�� CKWALL APPROVALS
steel
Electric Bond
Set Backs
Footings
Bond Beam — ��
Main Drain
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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
A RE -INSPECTION FEE OF $30
WILL BE CHARGEDiIF THE APPROVED
LANS AND JOB CARD ARE NOT ON
A R E - IN S PEC
W 'ILL BE CHARG
ILANS AND jot
T �c SITE
FOR
I I Spt SITE f OR A SCHEMED—
N TIO
SP ION.
0 0
CITY OF;'LA QUINTAL
BUILDING'. &.SAFETY DEPT
ARPR 'OVED
F-OK'�eONS`T�'-' U, C ON
DATE 4 By kle)
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