0104-026 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter,_'=commencing with Section 7000) of Division 3 of the Business and
Pfofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Sims B
Date Signature of Contractor
126:s112i
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).
() 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 SectionB&P.C. for this reason
Date t . J"' Signature of Owner'
r 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 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:
Carrier ' Policy No.'
(This section need not be completed, if the permit valuation is for $100.00 or less).
(t A) 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' compensation provisions of Section 3700 of thg Labor
Code, I shall forthwith comply with those provisions. ,e� /°`l
Date f m K kt Applicant
;.fig' e. el �.. •'9v'�.r ,« .
Z,,`'Warning: Failure to secure Workers' Compensafion_ coverage Is unlawful and
shall subject an employer to criminal penalties and civil fines up to $ 00, in
addition to the cost of compensation, damages as provided for in S t® 706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building a i Sa ety
for a . permit subject to the conditions and restrictions set fo t 1 on his A
application. -
1. Each person upon whose behalf this application is made & eac perso vat
whose request and for whose benefit work is performed under or F orsuan o (
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and
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 inspec(ion purposes.
„,Signature (Owner/Agent -��x 9 - �' Date
BUILDING PERMIT w PERMIT JJ
DATE VALUATION LOT �ta �'�� TRACT
VWX1; :: F 25CiU 3
JOB SITE
APN
ADDRESS
53780AWMDA V11,14
1774-174-0115
OWNER
CONTRACTOR / DESIGNER / EN (NEER
pC? w 1.179
81.9 YO A:4r' HUR 52, 4 0
.0C3INTt>, CA. 92253
T3 DR) 2201
(160)772-2848 C.B.L 6 1451
USE OF PERMIT '
P43C>L ANDIOR. a?PA
rn0011VAk 03MA” • PIRR /d Y WE.`,`bUM f dC'LfJ°D• Be P L U'1PAvRNT
:RR���1��g3:{.�`Xytp8�!«'..ica.LA}?EA�113ARRUP.0 MUST BE 0; PLACMAT }'REPSASTEP,
MMM, �.:ogr OF Ct3�;'a"��1�£�',ET4:��i
p p�ntr1y.►'°'�J.f+f
"PEI '.J.?,h�RJ� FAZE a'Sl:�i'17.r�t8. T
PIAV IN= Vow 102 0y.1 �.'�• � i � ���, ��
CCr?'dS' ? UCTION FEZ 10.1-000-418-000 $155.06
tddiaC.T'1ANKIIAL F& -- P00L. $14.00
E1.EC 1`W$rAL Ole?, — .POM, . B 01-000.420.000 $45,W
k'1,UMMO Rr • pool, 101-000-419-600 MOM
R 5 2001 ' •
.
ITY OF LA QUINTA&.flo) '.M, r,Cimmax-1 :gM1? m PlAm awx _
`' sm8,75
FINANCE DEPT IX3-3 PRP--PA•tr,T"s)ITIM
$0;00
RECEIPT
DATE
BY
DA FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
oet 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
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
�^ -O (
_
s't .
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)