0302-068 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
1�- Chapter 9 (commencing with Section 7000) of Division 3 of the Business
(V w Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
ti tJJ '7t 805 13 C$ Tvt�
Q' i
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c Z Date,— Signature of Contractor,
CD 0
JU OWNER -BUILDER DEC ARATION
cD
HWd r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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).
LO () I am exempt under Section , B&P.C. for this -reason
O N Date Signature of Owner
rn
d Q WORKER'S COMPENSATION. DECLARATION
p cr I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () I have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O _ Q performance of the work for which this permit is issued.
m QU (�) 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
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
1* Z Carrier ST.A Eg 1? FIND Policy No. 16103616-02
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J - - (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 pe rmit,is Issuetd,
I shall not employ any person in any manner so as to becope subject to e
workers' compensation laws of California, and 'agree'that<if should become
subject to the workers' compensation
provisions, S,acti 700 of.�K Labor
Code, I sh II forthwith comply with.tfiose'provisions
Date: !���� Applicant,-_-', `<�'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to•cnminal 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 i
work is not commenced within 180 days from date of issuance of such.
permit, or cessation of work for 180 days will subject p�rmit>to cancellation.
I certify that I have read this application and state tha-ttie,abovelinformation is
correct. I agree to comply with all City, and State:17ws,relating to the building
construction, and hereby authorize representd&esf�f�iis�City to enter upon
the above-mentioned property for�pec i cposes'.
Signature (Owner/Agent). • .:r "� Date >r
BUILDING PERMIT PERMIT#
£8
DATE \�4�Yd t2o VALUATION ®A A1Q LOT TRACT 28601
JOB SITE
ADDRESS ^'37-747 C F—RIRUDE WAX
APN 645W0.94T`
OWNER
CONTRACTOR /DESIGNER / EN (NEER
ME?rIEWI E-0, LP
DCD i:}r, V., :€NC &B.L?:.T.1.12TCM0 DEV.
74.760MOfIWAY) )1 10,200
78-6W. HTf?s3?t`+!n`AY.11.1,
RMIM1 RIS CA 92210
:LA f,,??.f`I1` TA, CA M253
£760)771-x345 CUN 2160
USE OF PERMIT
O1FNEWr "BIMM140
401 LF. 6' } LAOI .K WALL (EQUII'MEHT FNGL i.S"l; R.&)? t RCID SYS'! AM
i
6 M WAU., 40.00 LF
J?:IMAWMD CMT OF C ONSTRUC.".3ION
PFMAGrrYVIR S %%MMMY
MNSTRUCTION FREE 101-00041-18-000 NiW
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CO"0 R .71,a1E�:l�f',AN11T` z�%.�1q C^�ZC7
$25.00
LEMS I~':f LI-PAKWe F1 MS
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$0,00
p
� 103 TsYrAL, VWMT 1MRS�'cTY, NOW
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DATE q
BY
DATE FINALD
INSPECTOR
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
- 7. O -j-
Electric Bond
Footings
Main Drain
Bond Beam
/ �-d S'%
Approval to Cover
Equipment Location
Underground Electric
Final
Q
Underground Plbg. Test
Gas Piping
PLUMBING AP ROVALS
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)