0104-303 (PLBG)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
CD I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE i VALUATION LOT 01,04-303 TRACT
04 W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
�j JOB SITEV APN
I 0 " i �' •'� ADDRESS
LLJ 2921 Z2 (112 7' W.,s"' � / •3'vt w�t�� ,' 80-&A6 WMIXd?P.tr' _ w
'nxr yi �
Z j Date " "` f't Signature of Contractor -.r -� OWNER CONTRACTOR I DESIGNER/EN (NEER
J U [y OWNER -BUILDER DECLARATION 'r"vov'ATIVE.7<maol?;d`commm MOM,INC, �*TTCIMKOLAW'iO.faA&D,40,;k" C,
H LLJJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's 200 EK. 'K,1 AMWOTONAW. 0100 21165 G1UFMMfrORD.
License Law for the following reason: CA 92025 RAN W.RC08 CA 9.21069
Z ( ) I, as owner of the property, or my employees with wages as their sole C760)744-7910 MIX .582.E
compensation, will do the work, and the structure is not intended or oflared for
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals'�'iT1ZCd
Code).
C () I am exempt under Section , B&P.C. for this reason 11,Tle, D CTAS UN It TO NXW f7 8Q
O N Date Signature of Owner ANSI ;r AU-SO-t"i
rn
0< WORKER'S COMPENSATION DECLARATION
D Ir I hereby affirm under penalty of perjury one of the following declarations:
p O 1 have and will maintain a certificate of consent to self -insure for workers' "V�ihd)►�S']C9.�aiD.i4 Tris"
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
10_ 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
w O 101TATE F`WJT7 �gf1 � `997 •i)I Ess71 "ATYL C£3x"�' C1 ' d:�l d7 TIO+SW` ,M'�i3fi f9fJ
(This section need not be completed if the permit valuation is for $100.00 or less). qq yy 99' ay,A�$yt��I7}r�� 66��'pp y°'J91p MITA 14. Eyy a tf }�
() I certify that in the performance of the work for which this permit is is'siieAd,
S:�LIJI AM BI ILII .!` IS, . 0 A -000-419-000 S }. if 00
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, andragree,tjat if I should becdme
subject to the workers' compensation prov sions of .Section 3700 of,the Labor
3 Code, I shall forthwith comply with those pro"vi iorns
t �....,,,. , .
Date:/—
Applicant -?a r-
"—VVarning: 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 't°rt'AfT"I�R�Ti;°t(ih� }hvt33?31 �,It`FC°km1>'3.a(4
any permit issued as a result of this applicaton agrees to, & shall, indemnify D n M ME -PAW FSTM $0.00
& hold harmless the City of La Quinta, its officers, agents and employees. IN
2. Any permit issued as a result of this application becomes null and void if , , n T 'MMS DT.I N QW $1.%00
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. APR 3 0 2001
1 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 CITY OF LA OUINTA
the above-mentioned property for.inspection'purposek
RECEIPT BY DATE FINALED INSPECTOR
Signature (Owner/Agent)°`' '" —��� Date �_ '�'f ��
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
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: