0104-305 (PLBG)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT 0104-30! TRACT
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date �y
/ JOB" ITE APN
292'157? �,�:°"ADd'REss d r
Date" 31 Q Signatgre-,6f Contractor 0a4t r ' p . •1 OWNER CONTRACTOR /DESIGNER / EN INEER
OWNER-BUILDtR DECLARATION INNO'6'!ti'.WIE ri '.IRT CC3MvliJNrr"ih_,4, JXC.', liWJ"rOIRA1`13 ulwxgi"'lwa, INC.
I hereby affirm under penalty of perjury that I am exempt from the Contractor's 240 E, WA0.F.1 (p'"3 _YN AVF_ 0100 221 165 f'!1XMHAVJ.U4RU
License Law for the following reason: FISCOMYID0 CA 92025 SAW MARCOS CA, 92069
( ) I, as owner of the property, or my employees with wages as their sole (`?W)744.7910 ay" 56,71,
compensation, will do the work, and the structure is not intended or offered 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 r'.i3311 JCS
Code).
( ) I am exempt under Section , B&P.C. for this reason UX >�tdO C.gA. f.Ih1 Tia Tt Af/ id Q
Date Signature of Owner ANDI0.221"M'594$
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' 'VALUATION 1..9
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 issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
13? �N 111 �5a 2,09.13%_0 X8:!'iWATR,'� C'Oh" r OF CDRVIRf7C110N 12 600.0ii
(This section need not be completed if the permit valuation is for $100.00 or less). .1�'.'1?�14 '.gfIT. 999Mb RY
() I certify that in the performance of the work for which this permit is issued, 1FlIUMBINO YER 101' -00014 i 9_000 SM09
I shall not employ any person in any manner so as to become subject to the--
workers'
he.--- workers' compensation laws of California, and agree that if Jeshould be -66;e
subject to the workers' compensation provisionp of Section 3700 e, �.or' _
Code, I shall forthwith comply w „thosen [ovlsro
Date:
.. lel
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer toIcriminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Sectiori 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 t041d ' � �(� A 01
any permit issued as a result of this applicaton agrees to, & shall, indemnify D 1111128 PRE -PAM, FTM $0100
& 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 IVY—it M. 'S DUE NOW
work is not commenced within 180 days from date of issuance of such APR 3 0 2001
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 IawsreCaiing to the building u CITY OF LA OUINTA
construction, and hereby authorize represer9tiVes o this'City to enter upon FINANCE DEP)'
the above-mentioned propert ,f( 'nspecliorr , taKpose�.;
RECEIPT DATE / DATE FINALED INSPECTOR
L
Signature•-(O'wned4 g n� � � = r Dateai
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
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
_
S (a a!
Appliances
Final
Final
Utility Notice (Gas) i
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: