0105-103 (BLDG)''LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section MOO) of Division -3 of the Business and
Professionals Code,'and my License is in full force and effect.
License 2Y # Lic3., C16ss Exp. Date
Date X3
ow, 3 11 C9
Signature of Contractor 4(
;OWNER -BUILDER DECLARATION
11`"Fiereby affirm under. penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, 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, 1. as owner of the property, am'excIbsively contracting with licensed
contractors to, construct,the project (Sec. 7044, Business -& Professionals
Code). - '-I 5 .
O I am exempt.under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under -penalty of perjury one •of the following declarations:
I have and will maintain a certificate of consent to self -insure for Workers'
pomp6nsation,?-'as,provided for Sedtion*3700 bf'the LabDr'Co'de,"for the
performance . of. thi,wbrk for which this permit is.issupd., '.W
I have-a6d Will maintain Workers' compensation insurance, as required by
Ek5ion 3700 of the' Labor Code, for the perf6r?na6ce of the work for which this
"Per m*it is issupd.,my Workers' compensation mpensatio , n insurance . carrier & policy no. are:
Carrier Policy No.,,,%
'Ad?h NNIP
(This -section need not'be completed if thii-p&mit 46atioh,is, for. $100.00.6r less):
-()* I certify that in the perform.a6c'e of the work for which this permit is issued;
I* shall not employ any -person ih,any manner"ki as to become subject to,the
workers'. compensation -laws of California', and agree that if-ILshould become
"subject to theJw'o*rkers' compensation provisions ofSecti66 37 , 00 of tke Labor.
Code, I shat fort Ath comply With the S',I5r6viiions:
Date: L4tAolplicant—'
W.jrnin Fqilure;t6 secure Wor s' 66r�p6nsatioh coverage;is unlawful, and
shall 's U"gbject an employer to carinal penalties , I . .and civil'fines 'up to $100,000, in
addition
ddi on to the cost of compensation, damages as provided f6r_.in Section 3706
of tae Labor Code, interest and attorney's fees. ".'..%',: -
IMPORTANTApplication'is hereby made to the Dire6tor'of Building and Safety
fora permit I subject to. the conditions, ,and' restrictions ' set forth on his
�
application.
1. -Each person upon.whose behalf this application is, made & each person at
whose request and for whose benefit work is performed under or pursuant to
,any permit issued as a result of this'applicato,n 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 hull and void if
work . is. not commenced within 180 days from date of issuance ofsuch
p6rmit,' or cessation of work for 180 days will subject permit to cancellation.
I certify that, I have re.ad*this application and state that the, above information i
correct. I agree to bomply.with all City, and State laws relating to.the.building
construction, uction, -and hereby authorise representatives of ihis,City,td,,enter upon
the above-mentioned property for,inipectiori purposes.
;1, %-t Date t'e
2 rr/.. Z
gi�aiure ,(Owner/Agent)
BUILDING PERMIT PERMIT#
DATE VALUATION LOT' TRACT
JOB'SITE
APN
ADDRESS
-49-032M45 WA5'MXGT0.N SMIM
OWNER
CONTRACTOR I DESIGNER ENOINEE9
a
GAGOWWARD
qg.M,%A BOOIAG CO.
38-980 PANIM-0 L00 is yowl
LIN Wkrr.A. CA 52253
=10 CA 92203
(160)345--1,751 CB16. 12
USE OF PERMIT
GENMAL BIMM40
s vjjvUP A&Is'.00P CLASS A
P.Moof 4.219,00 L.8
Vn"EDT cfflnRunN
EYIrCOSMoa-TO
9ma
pnm NUMMR
i.
Sit, TOT il AND PLANTCHROH,
TZEIS PREIPAW
$30.00,
$01100
1
T: MIS Dint NOW
MAY 8 200
MOD
CITY OF LA 0 1 UINTA
FINANCE DEPT
RECEIPT
DATE
DATE FINALED
INSPECTOR
J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
p
Combustion Air
Exhaust Fans
Roof Deckf�8
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 6d�
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
COMMENTS:
1
A
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)