0011-088 (BLCK)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
l���;
r . , l..
pate .y� !�'• %Signature of Contractor
OWNER-BUILDER/DECLARATION .
I hereby affirm under penalty of perjury hat 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).
( . ) 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&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
Stion 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.
SLA.TH FUND 1h G�-Gtr
(This section need not be 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 m nner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject"to the workers' compensation provisions of Section 3700 of the Labor
Codd I s all forthwith comply with thole protisions..- f '
Dere:I i �^ Applicant I �
Warning: Failure to secure WorkersCompensation coverage is unlawful and
shall subject an employer to criminjl penalties and civil fines up to $100,000, in
addition to the cost of compe'nsa on, damages as provided for in Section 3706
of the tabor Code, interest andatttorney'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 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 ab 6 -mentioned property for/inspectiion,,,p�urMoses. 1
Si • nature (Owner/Agent) !� - ` ��.� Date t
BUILDING PERMIT PERMT#
DATE VALUATION LOTTRACT"•
JOB SITE APN
ADDRESS 7��•7 A
52,950 KKID •{/ Hal LYA
OWNER CONTRACTOR/DESIGNER/EN (NEER
JOE iid': #3''C1I�SJOIR .1P.. C014911
.
4,233 5 WOMIG'ON NT, 4355
:Nd3LVE DFMT CA 92211
USE OF PERMIT
120 LF. X F' COMZ1'NA!f ION o CITY STA11113A1Z O
4FT. WALL
JQTt W. ffirrENNIl? JR. COMM
423.35'WASIMvTM0..14 ST. 055
PAILM 271?&`�e'iU :""A 92211
QGU)360.931 5 CM4 2119
120.00 i1
:11;SMt!!:fl:M cC?s.ly Ciff C4)MSUCTION
Cf.>2+1MWIC'iIONN' FEE 10), -/00.41,13.000 1?.SUP
t
G�Cr`J3�41� �1 4,,ommcal.*0.L+'i .0am PullCl'tL'lt.0 $54,00
�p`:%9 2 ttT�p1E';„�'.�QAID 14ME J x$0,00
W,
6'F.�d.W.A9a,S" 7+.�s8Y.L413'S Re17{'d�n A!i�74 .+`fetiyi
RECEIPT DATE=BY(7/
" DATEFINALED INSPECTOR
t
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Footings
�l f'�. d S7
Electric Bond
Main Drain
Bond Beam
7 p0 LTJ
Approval to Cover
�(,y2—off S'r
.Equipment Location
Underground Electric
Final
1 _ _
12 �l X60 S%
Underground Plbg. Test
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)