0010-202 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9.(cbmmencing with Section 7000) of Division 3 of the Business and
Professionals Code," and myticense.is in full force and effect.
License # Lic. Class Exp. Date
ate
T4 r 0 1.131 /2
peite I () - Signature of Contracto�r�:,)
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 & Piofessionals Code).
1, 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
Section 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:
Cartier Policy No.
9TA'M FUND -00
(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 manner so as/tFbecome subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions ofS#6tion 3700 of the Labor
Code, I shall forthwith comp yt.. t ose provisions..,
/Date: Applic t.
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.
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 above-mentioned property for inspection pdrp'o'ses.
Signature (Owner/Agent)14 DateiWL'_ ;I OJ
BUILDING PERMIT PERMIT#
DATE i VALUATION LOT, TRACT
1, sa ro J X1214
JOB'SITE"- APN
I OWNER
CONTRACTOR/DESIGNER/
KATCA101 CORONEL cOR 0.1am Colonau cmcnq,
��,324 CALUTAMArZOLA 7 V - ) 5 0 CALLE TAMPIC0 VUM42.3 0
LAC 5:3 LA QV1WfA
)�UW A, CA 922 CA 92253
(760' )564-46M ";w
USE OF PERMIT
50L.F. COMWNAT1ON WALL (01 GARDEN WALLAW RYAWN11441,f 01I.00
ST MA
6 F11. IML
50.01Y
FZrMW= C017r Uri- COMMITIC310N
'VERWOPYT
PER K7. SUMWARY
RM 101.000-418-000 V1.00
PAID
OCT 31 2000
-V a IU LA NT
t- Qu
$0.00
TOTAI, MMn r,%U DWROW
RECEIPT I DATE f ' I BY , - I DATE FINALED JINSPECTOR
c.'r6.
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
Bond Beam
_ S'
�B�Zj('d�
D_ O 57
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Final
/ ZOID ( 57
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 l4' 38 -tie S
-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)