0107-220 (PAT):� -• - LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I— _ Chapter 9 (commencing with SectiC9 7000),;1 Division 3 of the Business and
01W f- rofessionals Code, and my License is in full torte and effect.
= ,M-' License # Lic. Mass Exp. Date
(� to �ol '
r` w r- 699690 D 03 Dg2 Z 1 n 1/2C
��..
oZ r DateSignature of Contractor �f r
r— I.— CD OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason: '
Z_ ( ) I, as owner of the property, or my employees with ,wages as their sole..-
compensation,
ole-compensation, will do the work, and the struclwe is not intended or offered for I
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).
ce) () I am exempt under Section , B&P.C. for this reason
to
N Date Signature of Owner
O C\
0)
. L Z WORKER'S COMPENSATION DECLARATION
`p Q Cr - I • hereby- affirm under penalty of perjury one of the following declarations:
r O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y= 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.
C0 Q U (v) I have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
fi � Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
nQ.
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 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 becpme
subject to the workers',compensation pr6visio'ns of Section 3700 of thabo,r
Code, I shall forthwith comply with the provisions.
t Date: -�/Applicant t7
f
Warning: •FailGre to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminalpenalties 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 ernter••upon
the above-mentioned property forr innspection purposes.
Signature (Owner/Agent)
BUILDING PERMIT PERMIT#
x,DATE VALUATION, LOT �;I,�-��(f TRACT
JOBpSITE `•`' T_r +
ADDRESS ,
APN
OWNER 4
CONTRACTOR / DESIGNER / EN (NEER
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RONALD
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USE OF PERMIT
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PORC'HIP.{>,TIO 3,F
PLAN CHECK MAD
w CON:iY'Fd.fta +d'1UN i?- 100,000-,41(4-0(A) $711 P
' `81TRONGMOTION F99 • RESID X01.10X -241-000 x,618
f
fib + i13CiI.., kiAND PL>A14•CHH(4
1119.30
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Jf{i.�`�
JUL 2 0 2001 ;�.�:.
V
"fl' 'MIS DICE N'Olff
-
CITY OF LA OUINTA
FINANCE DEPT i
RECEIPT
DATE1
BY
D FIyi4L)aD O J
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
Rreplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Finali?O��
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Sit 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�
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:
jti It7-777 71-77=77,��, `777
-lV6;
,,I -y OF LA QUIN IA
BUILDING & SAFETY DEPT.
rjoVED
APP
FOR CONSTRUCT
DATE (A �By
VFIVA ["C'Q.6
f, �" -,iv SUNLAND SCREEN & AWNING CO.
A., , 46080 CALHOVN ST.
A Cel TA e eP INDIO, CA 92201
(760) 347-0592 FAX (760) 775-5434