0110-252 (PAT)LICENSED CONTRACTOR DECLARATION
Thereby 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
777A.85 7".x1.85 H1.C"" 1.7�i'.i yi /Z(
Date Signature of Contract r w,p,
�-+.,....:'..'.-..•w..n'.u...:....Y.1rw
~ OWNER-BUI.. ; D CLARATI N '
I hereby affirm under penalty of perjury that I -am exempt from the Contractors.
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 & 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 Ownei
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( •) Ihave 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 1 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:
Cairier £ TA Policy No. 1,025-29 09
(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 to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensatlo prolVisions of Section 3700 of the Labor
IC de,
hall forthwith comply/wit ruse fovisions " "µ
'Date. ' + � `� Appllcan +"
Warning Failure to secure or, eK rs' Coensation coverage is unlawful and
shall subject an employer to,� inal pen ties 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 -land restrictions set forth on his •
Application. r..,,.
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 auth6ri?.4)/'representatives of this City to enter upon
the above-mentioned property fo';'Spe�tion purposes. ),,r! •
Signature .(Owner/Agent) �� r- p �'" t ,..Date .
BUILDING PERMIT PERMIT#
DATE qq(!SS/��jy��,��lr{{y{¢p'"VAL'UATIONLOT TRACT .,
'..�uV'-yV•a"L7pVYy {
ADDRESS S4475AV..I f�l'.I]DAVH4 A. -APN
OWNER CONTRACTOR / DESIGNER / EN (NEER
h -CO MOMP,P'MMA e:}Y3:IMP:jE �+ 3xw : witzrao & PwwC}mC aid co,
LA gGI3.�13`A. CA. 927,53 DIZAMMONT CA 92223
(909)so-9303 c * .
USE OF PERMIT
TIATI. % E
T''ORC;IfAPATI€3 300.00 SRS
F.93. )aA1�.'= �t��rF OF CG?NM><?CHON
P1,", CrHEC K WE 540,91
C,.0'?'.5STR UC%'100 FfX 101 -MO -418-000 o $63.Cr0
S"6'1?>i� I0 �.�C1TICINN R) iRES1D -'101-000-24.1-000AiA
f
a
uL
OCT 33 2001
CITYOF LAS QUINliA1
FINANCE DEPT.
i) ina, -co-qwlaualaom mio P.LmG3ri1
•
RECEIPT DATE. BY DATE FIN ED ,, INSPECTOR
INSPECTION RECORD
OPERATION 17_D
ATE
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 7�1�'-0 ��
BLOCKWALL APPROVALS
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
Gals Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixt&es
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: