0208-225 (MISC)LICENSED CONTRACTOR DECLARATION
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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
-D`ate CSignature of Contractorry�fr4 ,
OWNER -BUILDER DECLARATION
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 Code).
( ) 1, 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:
(J' 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 (+) 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 OT,A'p:E jtUND Policy No. M022
(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 f X00 of the Labor
Code, I shall forthwith comply oo
with those �Jrovi
Dater-- i r it Applicanti-
Warning: Failure to secure Workers' Compen ation 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: -
4' F, Each person'Lpon 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 applicator agrees to, & shall, indemnify
A hold harmless the City of La Quinta, its office rs,,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 arid state that the above information is
oorr'ect. 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 /m'sp ctictionn'purpo es.
Signature (Owner/Agent.)'F'<`� G"'` % �• ' Date�''�'
a;
HOLDING PERMIT
PERMIT#
'
07
DATE VALUATION �LOT
TRACT
JOB SITE ' ' i 4��
ADDRESS
APN'
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Lt1. i� r1�s :Cly i .F k
07-�u�tX WAY DEWEX)MG-M.7 WC
29395.6,01)' AROAD 0-2,,04
.7.93,.P5 A»tMR.TWAD #204
ACC %�:a�.x' RILLS CA 91.101 S0't
AW.T#LAEMU CA 911301
(31e) -V94800 c B.4)
USE OF PERMIT
PERMIT
)ESIVAMMID COS' 006;.'ON4'TRU 110P 0A)
C'ONSTAUCTION PER 101-000-418-OMI SWI '
v X HANIC.A,1, PEE
KLEC ,:iICAL,FE
A
D Q �
JAN 15 2003
CITY OF LA QUINTA
FINANCE DEPT.
.kms ..
s , -PPM. -21 ats{} o
41A
RECEIPT r DATEBY DATE F ALXD NS TOR
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 fi
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: