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61
LICENSED CONTRACTOR DECLARATION
Ibttereby 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. w
License # Lic. Class Exp. Date
53101 E hic 61.10104
'I n
Date 4'•- Signature of Contractor
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 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:.
Carrier ;`STA" :yiTD Policy No.
(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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: ; r , , s Applicant
be
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 purposes.
Signature (Owner/Agent) Date z _,_'- i "I-
BUILDING PERMIT PERMI0
r3209-:183
DATE VALUATION ,rj+M LOT TRACT
JOB SITE `
ADDRESS 50-115 {V&JBA A COURT
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
' �j. O'KARt A02,1AC
S1 mon CE3idK)R.'4L' IO)ST
COLTI4171T C IUD DMVFI SITII', 137
77-645A COUV Y C..;UB DRIVE- SMME 150
PAUJA DESMI, CA 92211
PPL14.DM131Xr CA 922601
USE OF PERMIT
WWTjN711ALkDDr3 ION
FoUP1}LEMENT.AL TO PERMIT it 0304rO J4+': C NVCR. ISN OF 1 CAR
0ARAGE TO TdETRM.'{' DkfbiiNG NITYAi.; c t0j43TR 3� 011, PER
.A.PPIROV'ED PLANS
C"D8701,4 CONIST11UCT10314 200.00 8F
'IMID COST OF COMM7,MMOM
PLAN Cd?1? M fti - -. 101.060 39.3 P ER Sir/lis
w I~CiNSTRUL'"`31UN YEE 101=000-4£x-000 �a�33.f98
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.98. ✓i %
00-445,t311J
A.Fd. r lea; PUDUC PL.i C.Ui - h' if t 210,000-445,000
Al
801-4 UT'AL CC'JMS�h.'Cif"'1'1"ON fi',LJNX �':d-lMM',
$256.07
l a.'N' M T' t'-P.EAID i`.t.M
$0.00
TCYrAL M70W 14'"M PT" NOW
$114156107
RECEIPT
DATE P{y
BY
DATE FINALED
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
0. 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
BLOCKWALL APPROVALS
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
Gas Test
Appliances
Final
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)
COMMENTS:
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