0007-255 (BLDG).-LICENSED CONTRACTOR DECLARATION
I hereby affirm.under.penalty of perjury thatI am licensed under provisions of
r; Chapter 9 (commencing With Section 7000) of Division 3 ofthe Business and
p.-,Pro,fessionals.Code, and my License is in full force and effect. ;
License #• , c Lic. Class Exp: Date
622122
Date Signature of Conbactof
OWNER -BUILDER D ORATION r
r
I hereby affirm under penalty'of perjury that l 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 Ahe 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
l hereby affirm under penalty of. perjury. one'of the following declarations:
O 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,
pifion
rmance of the work for which this permit is issued..+ k
I have and will maintain workers' compensation insurance, as regwred by
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. M 9094`
(This section need not be completed if the permit valuation' is for $10060 or, less)°
(+ I certify that in the performance,of ffie work for which this permit is issued,
I shall"not employ any person in any manner "so as to become subjectito the
workers' compensation laws of California,.and agre61hat if I should become
subject to the workers' compensation rovisio sof Section" 3700 of the Labor
Code, I s all forthwith'comply,withe pro s d'ns:
Dater 0 Applicant' -VU
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i
Warning: Failure -to secure Workers' Compensation cove rage'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
- c
IMPORTANT Application is hereby'made to the Director of Builjing and Safety
for a permit subject to' the conditions, and restrictions,' set forth ,on -his
application.
1. Each person upon whose behalf this application is n de & each,person at
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 off icers° agents, and employees.
2. Any permit issued as a result of this application becomes, null and void if
work is not commenced ,within 180days 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 rep• entatives of this City to enter upon
the above-mentioned propeM
nsp cti • purposes
A
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#.
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/ � 000.1-2.%
DATE %/��,'� VALUATION LOT :•. TRACT
JOB SITE
APN
ADDRESS 49-031 WAN.MNC;r01q WRE
^
'
OWNER
CONTRACTOR/DESIGNER/EN INEER
VD -JAS OF LA QUIMA P)A). .
Romim"T CONK.
49-031 W!r`
P.O. 1821
U, QT.iW.CA CA • 92253
LAQUWfA '
CA:
92253:
6 7-71
USE`OF PERMIT
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Pr,.P ,A,P.PRo eD Mmi n, 17N I`i' 2000- 506(14 VILLAS) O3TJ.Y
4 FT. WALL'
1�'`9 L75IA11 ? cC?u'i' 01P CC3ssrR:'�6 11i>1�f `
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PKRW.r 1• SUMMARY
,CONISTit1J.Ci'ION FEE 101. 00-418'.006.
SUB C09KRUM09 AIM PJC AW d '9-X
$15.fat1
7..�LW6 2'121? -PAID MLS
$0,00
TOYAL MERMTF EMS WE NOW
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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 6 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs /n
Footings
Bond Beam
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final _� --�� Ak
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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