0105-098 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that l 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
Date �" ✓ �F, °� Signature of Contractor
^" OWNER -BUILDER DECLARATION
I hereby 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).
( ) I,- 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, 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'
compensation., as provided for by Section 3700 of the Labor Code, for the
performance of the work'for which this permit is issued.
), I have and will maintain workers' compensation insurance, as required by
Section 3700:of the Labor Code, for the performanceof the work for which this
permit is issued. My "workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
Z'TAT& :7V %iCC1Gi��ltrd
(This section need notbecompleted if the permit, valuation is for $100.00 or less).
( ) ' I certify that inahe 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 the workers' compensation p_r•"visions of,Section 3700 of the Labor
Code, I s a fort `ith comply with tKose�pronlsions.
Date:,, � ,d Applicant' �''' .,r%.�i✓,,0�i ✓'`:� C
Warning: Failure to secure Wo r rs''Compensation coverage 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, iriterestand attorney's fees.
IMPORTANT Application is hereby made to the Director of Building 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. 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 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 from date of issuance of such
permit, or cessation of work for. 180.days will subject permit to cancellation.
I certify that l 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 r inspection purposes.
Signature—(Owner/Agent) 412i42 Date .., v'
-BUILDING PERMIT PERMT#
DATE VALUATION LOT ('910"98 TRACT
JOB SITE
APN
ADDRESS
49-071 WA;.HiNGTON CI dgr. '
OWNER
CONTRACTOR / DESIGNER / EN (NEER
49-071 WAMMG1101TIMMEX1.7
38-900 RAN -010 L056 COYOTES
LA QjMTA CA 92253
I DTT CA 92203
USE OF PERMIT
1
EfAd9. ATION %SQO, d Lfs
MUM COST M.'CONgrRUMON
R�"at' mrl 6J : s .6my
E:T:38t T1 RE 3 �3 �(10t3M4 i �-dta+i? i.�tt.£Sit
i
f.
MAY - 8 2001
CITY OF A QIIINTA
R CEIPT FIN RaEDEP
B
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 _ _
Roof Deck S//p/� ��
Combustion Air
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final / POOLS - SPAS
(((
BLOCKWALL APPROVALS 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:
4
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)