0104-082 (BLCK)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
�" 6>, Signature of Contra ctors?„_�
N• a
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).
O I am.exempt under Section B&P.C. for this reason
Date' s• Signature of Owner _
<”°y5 W.ORKER'S COMPENSATION DECLARATION
I hereby.Y'gfii ;under penalty of perjury one "of the following' declarations:
( ), I, -h, ave 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.
O l.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 Policy No.
(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.] should become
subject.to-llie workers' compensation provisions of Section 3700 of the Lab
,,Code IW. shall forthwith comply with those provisions.
Date ,o, .tky',w -:N. � Applicant
Warning: Failure to, secure Workers' Compensation coverage is unlawful a
shall subject an employer to criminal penalties and civil fines up to $100,000,
addition to the cost of compensation, damages as provided for in. Section 37
of the Labor Code', interest and attorney's fees:
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject -to the conditions and. restrictions set forth on h Safely-
for
1. Each person upon whos&behalf this application is made & each person ate.
s whose request and for whose benefit work is performed under_or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days fjom date of issuance of such
permit, or cessation of work for 180 days will, subject permit to cancellation.
I certify that I have read this application and --state that the above information is
correct. I agree to comply with all City, and State 'laws relating to the building
construction, and hereby authorize representatives, of this City to enter upon
the above-mentioned property for inspection purposes.
.• S' t OwnedA a ft''`l�, ` "Date -lss-O .
BUILDING PERMIT
PERMIT#
DATE VALUATION OT
0104-082 r T@ACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
M-1419
RUDYISUMPORRY
SFr
NES BOX F 093
3 `! 3'�? 'fid t$i�'�� �i� PA110. .
.i'.,AQUINTA CA 92253
MO"MMALdrY ' Ck 92234
(". T.A.
6346
USE OF PERMIT
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11 .Irl+ V OLL+"E:,lv': 4df'AL.I.,01g! STM. 1,ARD
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V.01MMUCTH PEP 101.000 -418 -Gad
y.
APR 10 2001
CITY OF LA OUINTA
FINANCE DEPT
UO3 PR.&PAW IiErM
G�:f1i1
RECEIPT
DATE
BY
DATE FINALED
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
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs _
Footingsf�2t f
Bond Beam /Z G
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
�i ,,-/
Final l//!�/ �% /�
Underground Plbg. Test
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
Suvfanels
Exit iar Receptacles
G.F.I.
Smq% -Detectors
Temp. Use of Power
4
Final
Utility Notice (Perm)