0103-097 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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C14 ui Professionals Code, and my License is in full force and effect.
O ce) License # Lic. Class Exp. Date-
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t- r- Signature'of Contr, ( , /_
Z r- Date //,
Contractor
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CID
J V OWNER-BUILDE%ECLARATION
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W III I hereby.affirm'under'penalty of p6rju , hat I am exempt from the. Contractor's
Cn License Law for the following reason:
Z ( )., 1, as owner, of the property, ormyemployees with wages as their sole
compensation,:will do the work, and the structure isnot 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,,& ProfessionaI6
docle).
am exempt Under Section < B&P.C. for this reason
C\1 Date Signatur'e'.'of Owner,
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< WORKER'S COMPENSATION DECLARATION
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C) 1. hereby affirm under :penalty" of rofthe
pejury, one , , f6liowing.,declafations:
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F.-; 0 1 have and will maintain a certificate of Consent to self -insure for workers'
LIL as`p'rcivided for by Section 3700 o
compensation, f. the Labor Code, for. the
0 _J __J performance of the work for which.this permit,is issued.
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C) I have and will maintain workers' c,o,Tpensation insurance, as`irequired by
O 0—: Section 3700 of theLa'bor Code, for,the performance of the work for Which this
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0) permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Cartier Policy No..'
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;:t (This siktibn-heed not,b6 completed if the permit Valuation is for $100.00OM6s6)O �
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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 is to become subject to the
workers' compensation laws of California,, and agree that if I should become
subject to the workers�Compens6tion provisions of Sec I tior� . 3700 of thee -Labor
Code, I 9haII'Jdrth %Ah comply
wItj^ i'thoge(pK666ris
ate:
pplipant
Warning: Fai ure to secure Workers".Compensation coverage is,unlawful and
shall subject an employer to cri6m[p6h'alties and civil fines up to $100,900, 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 ishereby made to.the Director of Building and Safety
for a -permit. subject to,. the Conditions. and restrictions. set' forth on, his
,application.
1. Each peison:up6n whose behalf this application is made & each person a , t
whose request and 6r.whose benefit work is performed .under or pursuant to
7 Any permit issued as'a result of this applicaton agrees to, & shall','indemnify
& hold harmless the City of -La Quinta, its officers,. agents and employees.
i Any permit issued
d as a result of.this'A'P'pl'ication becomes null and I void if
Yvork,is •not commenced within, 180 days from date ofisisbance of such
permit, or cessation�pfwork,for 180 days will subject permi . t to can.cellati on.
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 i
7pection purposes.
Signature (Owner/Agent) i Date
BUILDING PERMIT PERMIT #
DATE
VALUATION LOT TRACT
pry
JOB SITE APN
ADDRESS
48-975 WAISHYNG-Ton ry nm.,r
[OWNER CONTRACTOR/DESIGNER/EN &NEER
WIM MA&MRSON'
.Q 'fA CA' 92253
USE OF PERMIT
GVE� ",.ALBtMYZa,;G
SUIL.7UP R&ROM C%ASS A
auff'rom -Roon- N(f CO.
36-960 RIAITCHO UUM COMES
'INDIO CA 92201
VALUANION Y,'3
EMINWr" cost, OF COSM.1710310N
IAND PLM CHECK
UO3 PRE -PAID FEMR;
DUE .Now
M AY 8 2001
CITY OF LA OUINTA
FINANCE-DEPIT_
RECEI�L* BY DATE F IN AL ED INSPECTOR
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 j /�
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 /%8/'�'
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 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
Appliances
Final
COMMENTS:
>. `
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.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)