0105-105 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
62540 C.3 9
Date %'*U) Sigriatuie 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:
( ) I, as owner of -the property, or my employees with wages as their sole
compensation, will do the work, and the structure is riot 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).
( ); I am exempt under Section B&RC. 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 toself-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
S ction 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.
TATE YWID
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 theworkers', compensation provisions of Section 3700 of the' Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' 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, 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..
F,
1. Each person upon whose behalf this application is made & each person ae
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, indemnity
& 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 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.
J ,� f.
�Signature -(Owner/Agent)�� 1 �'`k",r / Date
.. ..,... ,... ... .,�... ..--. -.ems. �. ...... ....,._ ,.w.,.....,....._. ...�.. ,.... ... M._. _..- ...,... ,. ,,.. .�. _. ....
BUILDING PERMIT PERMT#
DATE / J VALUATION LOT TRACT
TRACT
$4,
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN &NEER
M/M pmaar?
C U 1`CJ3uY R0011wo C01
49-•191 VIM-1.11NUTON T -W
38.960 R&,TC:10 W3 COVY17101
LA QUYJ.,TrA CA 9225J
1hT.A0 CA 92203
USE OF PERMIT
,tztiH T UP lit&I.00F ('114A35 A
RE -ROOF 4,2MOO
-;5
COY
11MMIT1511a SUMMARY
COMM .
T. N PM -PAW 4
4�. e�0
D a•o now
MAY -82001
R CEIPTB
DATE FINALED
INSPECTOR
Lf
INSPECTION RECORD
OPERATION --_.17--DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUi�-iWd' APPROVALS _
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade z'
Retum "Air ,
Steel
Combustion Air
Roof Deck /3// �/e`
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 ��
BLOCKWA it , PROVALS-
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: