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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of DivJJ'sion 3 of the Business and
Professionals Code, and my License is in full forcerand effect.
License # Lic. Class Exp. Date
74.098 B C 10
111 ignature of Contractor:
OWNER -BUILDER
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 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.
( 1) 1 have and Will maintain workers' compensation insurance, as required by
S'4stion 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:
Canter STATS FUND Policy No. 046-010009232-02
(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 Cal' mia, and agree that if I should become
subject to the workers' compensatff provisions of SAdtion 3700 of the Labor
Code, alV1 h comply wit ose provisions.-^."�"'
,f�ate����� �L�ApplicantT� �-/'
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 I have read this application and state that the above information is
• correct. I agree to comply witp all City, and State laws relating to the building
construction, and hereby au horize representatives of this City to enter upon
the above-mentioned prope or inspectint pu os
_Signature (Owner/Agan - Date n/ o
BUILDING PERMIT PERM0
1-117
DATE VALUATION LOT
LUTRACT
JOB SITE
APN
ADDRESS 77-V.OrCAIXEr'IYU PAZ~I[30
OWNER
CONTRACTOR/DESIGNER/EN (NEER
ROY SC'.11Uf3Fk'T
A & 14 CONI IZUM- 7. all
P101 WX 366
78.070 C, UE? CA=.
LA QUI 4TA CA 332$3
LA QZ1II r A CA 9225:3
(760)564-4832 C31.06 626
USE OF PERMIT
ORNETat L BUTL3: EN
123 LF 6' BLOCK WALE, PKR OPCO SYST11M
d FT. WALL 122,00 LF
FS"MOTAI UD COSH 13F CONSTi UCTION
;v im+
PERMIT X d7 E NUMAMY
'
CONITFR CTION FEZ 101 -WO-41 $63,40
tNOV t2003 1
CITY OF LA QUINYA i
FINANCE DEPT. ,,,,-,i
SUB-TOT.ILL.. L0NZ iT?.1 C°T 0X .AN -D PJM' F:1 WCi.
$63.00
L-TQV PRE-PAID;Y.,
$0.00
'.C(YTAL 9'P1d%I!':t 1F +' US a)UK 14OW
S_63m)
RECEIPT
DATE_
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BY
DATE FINALED
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INSPECTOR
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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
Root 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 Unes
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS a SPAS
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 Unes
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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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