0102-090 (BLCK)L."ICENSED CONTRACTOR DECLARATION
I e-reb s'cJer penalty of perjury that I am licensed under provisions of
Chapter encing with Section 7000) of Division 3 of the Business and
,Professional e, and my License is in full force and effect.
License,# ` Lia Class Exp. Date
Q$ r3112
Date SigVure of Contractor
1`
OWNER' -BUILDER DECLARATION
I hereby affirm under penaltyoi,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
tractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am.exempt under Section , B&P.C, for this reason
Date a Signature of Owner
WORKER'S COMPENSATION. ' ECLARATION
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 perfomiance of the work for which this
permit is issued. My, workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
It,1F3i, PT
(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,
Iuall 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,provisior�s:�^
Date: Applicant 1,.,
/ f/
}` 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, indemnity
& hold harmless the City of La Ouinta, 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 (OwnerlAgent) ^• �'=°"�" � Date-' !'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0102 -iia TRACT
JOB S1TE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN &NEER
LA. QU;Et4TA PALMS RFAUY
TOP OF, :LSE SIGNS
511.001 MUM 1 OWIM DRIVE
51300 A )IDA' I R INZA
.L. k ( u7 r.k CIA 92253
LA. QT.I"M'A CA 92253
(' 60)56A-4246 C%Ut 5789
USE OF PERMIT
QI:M: LALIsX:tf.I.T)WO
ti L. V. 4'H 0AP.M41 VIAW, • CIT Y STE1NOA1UVONIUMi! .' T SION AS PF.R.
4 FT, WALL COD 11F
COST OF OONS.1RF;FMON
�E.VrD4A1FD
t;GiN„ i Ft,Ui^TIEaAT I�� 101-000-418-000 1.000-418S-000 51100
SIM -TOT ,lk t:. C'C►.VIVIR'<?Mag AND PLAN (Mll: rX
$15.00
I Mi S PRA -FAM PM, '
$0100
RECEIPT
DATE
/,__�
BY
:
D INA D
a 4Z9/
INSPECTOR
' t
'
�
HSPECTM [RECORD
OPERATION
DATE -7
INSPECTOR
OPERATION
DATE
INSPECTOR
BWLD0NG
APPROVALS
MECHAN9 CALL, APPROVALS
, Backs
Underground Ducts
& Footings
Ducts
de
Retum Air
r�s
l
Combustion Air
f Deck
ExhaustFans
.to Wrap
F.A-U.
Framing
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Flrgwall
Exterior Lath
Drywall - Int. Lath
Final
Final
o LL,OCKWALL,L APPROVALS
POOLS e SPAS
Steel
Set Backs
Electric Bond
Footings
Bond Beam
.®
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
f��,�DMC� NG 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)
ELECT=AL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: