0105-100 (RR)LICENSED CONTRACTOR DECLARATION
U) 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
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C14 UJ Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
irI� CY LO
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r— C39 1311, 2
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Z t, -Date PaSignature of Contractor61:_�_Iwl
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C3 OWNER-BUILDER,E;ECLARATiON
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a -
U) License Law for the following reason:
Z_ 1, as owner ofthe 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).
Co
LID I am exempt under Section 'B&P.C. for this reason
N Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION
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C) CC 1(
I hereby affirm under penalty of perjury one of the following declarations:
U-) < - ' ) I have and will maintain a certificate of consent to self -insure for workers'
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X ILL! LIL. compensation, as provided for by Section 3700 of the Labor Code, for the
0 _J < _J performance of the work forwhich this permit is issued.
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'< 1 have and will maintain workers' compensation insurance, as required by
O Section 3760 of the Labor Code, for the performance of the work for which this
10L LO issued. My workers' compensation insurance carrier & policy no. are:
z permit is
— Carrier Policy No.
ob 5 XTATZ MID'
CY
< (This section need not'be, completed if the permit valuation is for $100.00 or less).
_J 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 thgOworkers' compensation provisions of Section 3700 of the Labor
Code, o Ode, I h Ifora with comply withthose,66igions.
U_Dntpl
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.�_I I., Applicant VlAe�l
Warning: Failure to secure Worked' Compensation. coverage is unlawful and
shall subject an employer to criminal penalties and, civil fines up to $1 00,0bo, in.
addition to the cost *
of compensation, damagesas provided for in Section 3706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of BuildingandSafety
for a permit subject . .to the conditions and restrictions
estrictions set forth' on his
application.
1. Each person upon whose behalf this application.is made & each person at
whose request and foF whose benefit work is performed.under or. pursuant to
any permit issued as -a result of this applicaton agrees to, & shall, indemnify
f & hold harmless thj , City of La Ouintajts�officers,'agents and employees.
2. Any permit issu,e.d,as a result of this application becomes null, and void if
work is not commended within 180 days from date of issuance of such
permit, or cessation of work fur 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 authoriAe representatives of this City to enter upon
the above-mentioned property/Vinspection 'purposes.
ell
LSignature (Owner/Ageni�-,/A,, Dallt� 40
y
-A. I -
BUILDING PERMIT PERMIT#
DATE P VALUATION LOT (9105-1. TRACT
$4 2A
JOB SITE APN
ADDRESS
OWNER CONTRACTOR DESIGNER EN (NEER
1101H EMIR"E"K C'MMOM R(I)OHNG Co.
M-980RANCIRMS CON`0,170 -
Lk QUTWA CIA 9225-3 0M10 CA 922,03
(760)345-3-151 CBur, 12
USE OF PERMIT
BUILT UP ",R00 -R. Ch_ US A.
RECEIPT
VALUA710N
F8'MVAJXD Cdorr 0F CONUMiCnOR
MAY 8 2001
CITY OF LA QUINTA
FINANCE DEPT,
AXI)W CIR Mi
1=3 FRFNPXX� FQ0
P IM, WW 11"'M DUENOW
BY I DATE FINALED IINSPECTOR
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 �_���
`7 "
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 Walt Firewall
Exterior Lath
Drywall - Int. Lath
Final 6v
BLOCKWALL APPROVALS
Final
POOLS -SPAS
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
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: