0206-153 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect. //
C � ch License # % Lia Class 1 Exp. Date
W/ii51 ' rit7if31f2f
� W
c ZO r- /bate "' `r � � %)/ Signature of Contractor
l.�
r U OWNER -BUILDER DECLARATION
HLu I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
co
( ) 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
L
N Date Signature of Owner
O N
0)
FL Q WORKER'S COMPENSATION DECLARATION
.0 Z I hereby affirm under penalty of perjury one of the following declarations:
-r O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W LL 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 Q U)° I have and will maintain workers' compensation insurance, as required by
°QQ Section 3700 of the Labor Code, for the performance of the work for which this
dLO LO permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier (51TATE 1"D Policy No. a
Q (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 Fs`hould become
subject torthe workers' compensation,provisions of Sectiort'3700 of the Labor
Code, 1'sl all fdrthwith comply with�those provisions,
,,,Date: Applicant-
Warning:
pplicant Warning: Failure to secure Workers' Compensation covera°ge,is unlawful and
shall subject an employer to criminalpenalties and civil fines up to $100,000, in
addition to the cost of compensation ,idamages 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 autliorizef�epresentatives of /this City to enter�up�,/
the above-mentioned property for inspection purposes'
L,., -Signature (Owner/Agent) `' '` Date
BUILDING PERMIT PERMIT#02C4^15
DATE gam VALUATION smo•) LOT I TRACT ELK 159
JOB SITE ADDRESS 52-775 i�VXVWA . z u APN 773-324-414
OWNER CONTRACTOR/DESIGNER/EN INEER
PAV1.LI ROSS haLLElt PACOCTRADES CyOt'7:j`iTX7MON
1719 S TRYMOM 1 "r 19 S T_ .t'(:XVlolgz
S OCMNISIDE CA 92054 S GC'SLkMff)z C.A. 92054
C760)967-0069 OBLO. 1955
USE OF PERMIT
oti-IT-11XLE1. HMI90
.26 LF 6' C"A;P.`CPEN WALL PXR CCf'Y ST.A.NDAIC0.
6 FT. WA11L
26,00 LF
Ef"31MMED COST OF C i?I`i91RUMON
F,M1 :'bT.E SUMMARY
C0143TRUCT1ON ISE 101 -000 -436 -OW $19"00
z rfs r
'VFju4,, 1 9 1lm
OFLAWNTA
SIM -TOTAL COMMI•s' UCTIC)N AWL) PEAW C*i� . •:ita 1.
TOT&L ITIM r FEES DUENOW
(RECEIPT DATE Fr , ,r/ c B i DATE FINALED INSPECTOR
KOM
$19.00
$0.00
$z9A30
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APP OVALS
POOLS - SPAS
steel
Set Backs
1p L
Electric Bond
Footings
Bond Beam
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground P1bg. Test
Final
Z r/L ��
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: