0204-126 (BLCK)" LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commericing with Section 7000) of Division 3 of the Business and
C14W Professionals Code, and my License is in -full force_ and effect.
O M License/ Lic. Classj¢{{////� Eiz*
D to
r W r r i-� �k F 1i i��fwt
Z V Signature Z � � Date Signature of Contractor E/ f � � � AA /
�O� it
H
C:) OWNER -BUILDER DE((((((/CLARATION
W W I hereby affirm under penalty of perjury that�� 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O N
G7
CL z WORKER'S COMPENSATION DECLARATION
C) Cc I hereby affirm under penalty of perjury one of the following declarations:
U') � O " () 1 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 J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
,It z Carrier STATEFUND Policy No. 1108706-99
ob Z)
r, a
J
(This section need not be completed if the permit valuation is for $100.00 or less).,
( ) I certify that in the performance of the work for whic�).his pa'rmit is issued,
I shall not employ any person in any manner so as toybecolhe subject to the
workers' compensation laws of California, and agree th�Af I should become
subject t$'t, a worikers' compensation pl�ovisionk, Se Ion 3700 of the Labor
ode, I'hdl brtti 't •co I with th sp'ef) r v sio
a Date: •4�App cant Y p�r� r'��f Ali
/ t v d
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to cri9inal/enalties 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 andney'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
(�v�p & 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•th the above information is
correct. I agree to comply witNall City, and State/taws relating to the building
construction, and hereby atfthorize representa� Fee of this City to ente upon
the a • ove-mentioned property or, insp ion LRrpose`s.
%SI"'gnature (Owner/Agent) Date
BUILDING PERMIT PERMIT/i
0204426
DATE0411 fdWC LUATION $3 897.00 LOT TRACT
JOB SITE n {�
DDRESS
APN 1
OWNER
CONTRACTOR/DESIGNER/EN (NEER
r l -675 AVMDA HIM A
45-260 PAW. ;Tr.
LA QUINTA CA 922�3
WOK) CA 92�,o
M
(760)'4473-8913 MU 401M
s
USE OF PERMIT
1801,E 5' PAN ;y.1,.00K. WAUL PER CITY S1AIw1'ia§.RD.
.t�It'UMTED COST 44" (1108414 2-CC,M
P*ryy59 91TAAyRM
C4?3;19 ILICTIOi FFE 101.0 0-1'18.000
r
i-'iY)'�'ALCCW , lldSC1;�:�t�3�i,�1'13I��T..M M3�GfC
$63.00
IX 33 'M -PAID IM310
$0.iyo
TOTAL T-OlMaT.17, M-XIS)DUR, NOW
,SECEIPT
DATE J /
BY _ r — - ""
DAjE INA D
INSPEC
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs _
Footings
Bond Beam S OZ, I
Electric Bond
Main Drain
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: