0112-057 (SFD)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
7.14074 Ps li :ESI e� t/G3
'bate Signature of Contractor �� t''"
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). '
( ) I, as owner -of the. property, am exclusively .contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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 issued. My workers' compensation insurance carrier & policy no. are:
Carrier, �,?.lRR-,31;A:.�k1BRUXU Policy No. i t: 31391 tl3
(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 3700 of the Labor
Code, I shall forthwith comply with those provisions /
,,bate: 1-1.1. i'-101 Applrcant;•• •-''
Warning: Failure tosecure 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
121
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;l. o
any permit issued as a result of4his applicaton agrees to, & shall, indemnify
-& hold harmless the City•of La Ouinta, its officers, agents and employees
2. Any permitissued 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 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 inspection purposes. ,
Signature (Owner/Ag tj� r ; "'' `^ /'_ -'+ Date
BUILDING PERMIT PERMT#
DATE .y( VALUATION LOT._-.-- TRACT
29960
JOB SITE �— - - . f
ADDRESS
Oo
APN
OWNER
CONTRACTOR/DESIGNER/EN INFER
Co1IA,,+��� `t"�+ C 110,WLIAM E�.3?�{��1£-c��t:�1�,NIM
fad �+g",dKIr.:y3p.'qRom UP ,gyp
.21 n80 VVC81'F3:J'1Lfl..AKI C.�f.Ci:t.7,-E f1 TT19 1,50
}� Ap ��
/ 1py � eY � SURE
2660 VCATi�M:ie!!�'Y �..0.1�'vIZ, SU i.E 150 .
CORO A Gni 91720
C"OROWA CA
9-1720
(9001)779.4000 CUR
&761 .
USE OF PERMIT
SPP WT 3 PLAIN XR. P1r12.MIT C1ONS, i* O MC1d7D t,�q..;OL 9 WALJ-%
P00 SPA Oil DRIVEWAY A,PPROACH. %% REDUCTION TO PLAN C.149ex
4:1JS'i'OM C' 01481T UCT1014 4973.00 Su
PORC141PATIO 30010019,11?
C9A1tiPeC1+1 ARP097 6Si,Qt3 SP
CUNSJTK1(,4T10N 414F. 101-000-418-000 S1;161.90
tal.,AN C'F3ECK FEE 101.-000-439-319 V39,08
NI)W AtdWAL 1sU1C 3111.50
i 1,KIRICM, IFU $169.55
i?L(J'Mi3ING FEE 1091.000.419.000 $199,7
S`!°3om mi3nan m > mm 1 w -OW-241 $3A.$5
GRADIAlC+? :R3 1 CBt wt?t90�� 3�t3t?0 $�rti.Q13
'4WF A ST:rdUC*711RB PSS1
Ad{.7". IN PUBLIC P'I.AA013 - 1tES,1E VO -000-445-000. "3120.8?
. LAW
A70.1.16:�A L,c9da,L.+F�,.}.®6`��.1'.1iWt.l4lXA56 1`d.�.6�
DEC.-I 3.2001
,RECEIPT -.DATE
r
BY:<
KILCIPFINSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Slab Grade
pep fDucts
63�/� %l LL
Underground Ducts
Return Air
.�. _
Steel
Roof Deck
_
_ O} (�
Combustion Air
xhaust Fans
O.K. to Wrapf
�y
F.A.U.
a
Framing
Insulation
_ _
r • �� Compressor
� ,/�'j� Vents
�+
_ _ _ _
Fireplace P1.
Grills
Fireplace T:O.
Fans & Controls
Party Wall Insulation
Condensate Lines
((/1
Party Wall Firewall
Exterior Lath
_
_ O�
Drywall - Int. Lath
Final
Final/� pA _ -^. _ .
l .
POOLS - 'c AS
BLOCKWALL
APPROVALS
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
Waste Lines
Water Piping
��a �i
Electric Final
Heater Final
Plumbing
Final
Plumbing Top Out
Shower Pans
_
.9L 1"��— _
Equipment Enclosure
O.K. for Finish Plaster
Sewer LateralPool
Sewer Connection
d' 4 . may✓
Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
(Gas)
s ,t -v_
ELECTRICAL At'PRO
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
_
Exterior Receptacles
G. F.I.
7
��—
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
/
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