0105-099 (RR)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
I
Professionals Code, and my License is in full force and effect.
M :License # Lic. Class Exp. Date
Date t`� Signature of Contractor~` r O
C ` "� 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).
M ( ) I am exempt under Section B&P.C. for this reason
LO
N Date Signature .of Owner.
N
M
Q WORKER'S COMPENSATION DECLARATION
CCCC I hereby affirm under penalty of perjury one of the following declarations:
0 ( ) 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
_J performance of the work for which this permit is issued.
I have and will maintain workersi.cbmpensation insurance, as required by
U
Section 3700 of the Labor Code, for the performance of the work for which this
Hpermit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
M, ATE FUNDO 17
J(This section need not tie 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 I should become
subject to the workers' compensatlo�rnp ovislons of Section 37Q.0 of the Labor
Code,-IyshWI fortith comply with those provlslons.�
Date: e' e,: AnWic;'iht pes�A � / ✓
”'
' • --—Wirning: Failure to secure Wowkers Compensation coverage is unlawful and
j shall subject an employer to c61 inal penalties and civil fines up to $100,000,. in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to. the Director of Building and Safety
for a, permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made '& each person at
whose request and for whose benefit•work is performed ,under•or pursuant to
any permit issued as a result of this'applicaton agrees to, & shall, -indemnify
& hold harmless the'City of La Quinta, its officers, agents and employees.
2. Any permit issued as•a result of this application become's'null and void if
work is not commenced within 180 days from date of issuance of. such
permit, or cessation of work for 180 days will subject permit to cancellation.
i
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building ,
1 construction, and hereby authorize, representatives of this City to enter upon
I the above-mentioned property forhspection purpose
Signature (Owner/Agent) fi % �` � �°� ZAIV Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01—TRACT
KW,
JOB SITE APN ti=?
ADDRESS
.711
OWNER CONTRACTOR / DESIGNER / EN (NEER' z
MW LIMM 0U.M.KROOMIG Co.
49.111 WN T- 'OWN it,$ �'� IT 38-980 RMC1T0 IDS Z i%Y'Cy`.
LAQUINTA CA. 92253 Milo CA 9220 -At"
(760)343-3751. 1P 12
USE OF PERMIT
,
YA1,Y3tn.`PION
4100.0 La
;&,M),00
��3.%l�►�P' 1�1a. I ta:E Fl4�+��11 �3A�4.�3� $�0g4s�
/s�/�5�� q/t�•�,r. g�q� �97a'p'��•���g�,�q` - �v /�
AY��y{Jed.i�1�v%.."LJbe7S�J7`F.8•llHl..�F`d.+�¢Y.lK
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I MIS MIPAR)MIS $0.00
MAY - 8 2001 FUES DU IOW
CITY OF LA OUINTA .
.FINANCE DEPT
RECEIPT DATE/ BY . DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel _
Combustion Air
Roof Deck �_/�_
O.K. to Wrap /
Exhaust Fans
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
BLOC Al ROVALS
.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 APPROVALSGas
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
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)
COMMENTS: