0108-167 (PLBG)LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty of perjury that | am licensed under provisions of
Chapter (commencing with Section 7000> of Division 3 of the Business and
Professionals Code.and myLkmnxoioinfull hoomand o#om.
uvonnp# ' uo.c/mm Exp. Date
�
C42OVWX
�p/e�q�CL Pod Signature o/Contract
' ^ �
`OWNER -BUILDER DECLARATION
|hernb amnnunder penalty of po�u��|ammem�hfrom h Contractor's ona�or''
o
License Law for the following reason:
( ) |, as owner cxthe property, or my employees with wages as thai,ao|o
oomponoaUon, will do the wu,x, and the structure is not intended or offered for
sale (Gev.7o44. Business uProfessionals Cndo).
( ) |, as owner ot tho pmpony, mm wxoms|vn|y oom/uoU//g wxh licensed
contractorsconstruct the project (Geo. 7044. avoin000 & Professionals
Codo)- '
() |amemmpuu��,Genm�_______.e&PC.for m�mouon_________
Date �n*mnu of Owner
WORKER'S COMPENSATION
� DECLARATION--�' -
| homby affirm undo, penalty of perjury one of the following declarations:
( ) | have and will maintain ocertificate ufconsent moo|wnoumfor workers'
oomponoetion, as provided for by Section 3700 of the Labor Code, for the
performance ofthe work for which this permit ixissued.
| have and will maintain workers' compensation insurance, aorequired bv
S&tion 3700 of the Labor Code, for4he performanceof thekfomoxmia
permit is issued. My wn,xom' compensation moun,noo carrier u.pm/uy no. are:
Carrier . poUoyNn�
WAIT. FUND � `' ' . -91
(This section need not becomplet eUif.mepermit valuation isfor $1O0.0Omless).
( > | certify that inthe performance cf the work for which this permit isissued,
| shall not employ any person in any manner so as to u000mo subject tothe
workers' compensation laws o,California, and agree that if| should become
subject to the workers' a@ ;'_provisions of Section)3700 of the Labor
Code, I shall forthwith comply withLthose provisidhs_,��.i��
Warning: Failure to secure Zlkers' eo�pensation -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
1. Each person upon whose behalf this aplilication is made & each person at
-Whose request and for whose benefit work is performed under or pursuant to
'any permit issued aoaresult ofthis appicamnagrees to, & shall, indemnify
& hold harmless the City of LaQuintu. its officers, agents and employees. �
,.
2. Any permit issued oouresult o/this application becomes null and void if
*mm is not commenced within 180 uovo from date of ioovonoe o, such
pennit, or cessation ofwork for 18Odays will subject pe,mi(to cancellation.
I certify that | have read this application and state that the above information is
correct. | agree mcomply with all City, and State laws relating mthe building
construction,and hereby authorize representativesof this City to enter upon
16ignauue (Owner/Agent)ooto���������
PERMIT #
SPILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER ENbINEER1
CA
PAU'd DIMSWIV 'CA 92261
Cf W)346-27 93 CMA .342
USE OF PERMIT
VALUATION I's
111XIMBING RIVE SWER 101-000-419-000 M00
A 17 20]010
CITY OF LA QUINTA
FINANCE DEPT.
M033 PRE-PALD IM.33
20-104)
RECEIPT
DATE
BY
FINALED
INSPECTOR
1
�
U^
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts .
Forms & Footings
Ducts
Slab Grade
Retum Air
Steel
Comtustion 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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
I
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
7
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electri,, 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
R 0�
v/t��
Final
COMMENTS:
..
Final
Utility Notice (Gas)�Z
ELECTRICAL APPROVALS
—Temp.
Temp. Power Pole
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)
Few
o Plan Check Fees Water / Sewer '
"=`'
o nvnupuvmom-A.o
`
� b Customer oonoon
0 Other
�
`
x"1—nC'=o
ror�� � �
.`
� .`/
� namumv
pcs�y to:
Cash
Check
Money
101-5 aIcs.
'COACHELIA VALLEY WATER D STRICT
Flood plain plan
F11 58 7
ate
Grading plan
jived From:—
Subcontactor List
Called Contact Person
Grant Deed
Trac
Plans picked up
....—— --
Service Address
IN HOUSE:-
_Me
.
! o
_
Pub. Wks. Appr
, C3 """"~~~'
School Fees
u House La=="v
C1 Detector Check(s)
[3 Meter Surcharge
V/Sanitation Capacity Charge
�
' o Ws�.F.^
o Temporary Construction Meter
_
oTurn vnCharge
'
o Uncollected Account -
C3 inspection Fee - Tract -
Few
o Plan Check Fees Water / Sewer '
"=`'
o nvnupuvmom-A.o
`
� b Customer oonoon
0 Other
�
`
x"1—nC'=o
ror�� � �
.`
� .`/
� namumv
pcs�y to:
Cash
Check
Money
101-5 aIcs.
Plans picked up
Flood plain plan
Plans resubmitted
Grading plan
2" Review. reads, for corrections/issue
Subcontactor List
Called Contact Person
Grant Deed
Plans picked up
H.O.A. Approval
Plans resubmitted
IN HOUSE:-
3H
RevieA. ready for corrections/issue
Planning Approval
Called Contact Person
Pub. Wks. Appr
Date.of permit issue
School Fees
Water service
� �
Total Permit Fees