0005-117 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby 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
c,4V-* -z.; Professionals Code, -and my License is in full force and effect.
O :) M License Lic. Class Exp. Date
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r 7577 0 C29
r—
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Z r- Date Signature of Contractor',
(0 0
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r- C) OWNER -BUILDER DECLARATION
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W LU I hereby affirm under penalty of perjury that I am exempt from the Contract'r"s
F- n -
U) License Law for the following reason:
Z 1, as owner of the property, or my employees with wages as their. s leY�
compensation, will do the work, and thd'structure is not intended or offered f r
sale (Sec. 7044, Business & Professionals Code).,
1, as owner of the property, am exclusively contracting with licdinsbc! I
contractors to construct the project (Sec. 7044, Business & Professionals
Code)-
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( ) I am exempt under Section B&P.C. for this reason
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C\1 Date Signature of Owner
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d < WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations'
0 1 have and will maintain a certificate of consent to self -insure for wqr�kers"-'
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X W compensation, as provided for by Section 3700 of the Labor Code, for the
0_ _J < performance of the work for which this permit is issued.
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< have and will maintain workers' compensation insurance, as required by
b U QSection 3700 of the Labor Code, for the performance of the work forwhich this
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permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
ob 5 STATE FUND 1342223 -OD
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< (This section need not be completed if the permit valuation is for $100.00 or less).
_J 1 -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'shaljlorthwith comply with�tho�se provisions.
Applicant,
Date: - Y_ —7
Warning: Failure to secure WZrkers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines.up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
4 . 1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
.Signature (Owner/Agent),.' Date.—
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0(%(3: 117 TRACT
WV10)2(K
JOB SITE
ADDRESS 52. -OW faSM. TOW" W[W
APN
OWNER
CONTRACTOR / DESIGNER EN61NEER
Xpamr PHKLPS
JAWS FMOR MASONRY
.12-4320 ]W_BEW� OWJM DRNE
78-990 P.,AYD&RRY LAWE
1,AQTJWTA C.A. 92233
LA QUWA
CA
92253
(760)772-30336
10BU,
5713
USE OF PERMIT
(TENE-RALBUIMIgG
38LF. 6'(1f1'QARDM WAIL (ORCO STANDARD)
6 Ft WALL' x.00 V
MITMIATRD COST OF C01q1.917?.UC170J1$
P$0-00
PERK&W FRY, SUMMARY
C014STRUC-TIO14 FEE 301-000-418-000
MM -TOTAL CONS'fffi=1109 AND PLAX CkIRCK
$25.00
1X= PRE-PAT13 FERS
$0.00
AL F. kRMTF FEES DVE NOW
u5vo
RECEIPT
DATE
BV
JDATE FINAf
VA
JINSPECTOR
INSPECTION RECORD
OPERATION
AJE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
-Forms & Footings
Ducts
Slab Grade
Return Air,
Steel
Combustion Air j
Roof Deck
Exhaust Fans
OX 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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Footings �5�
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final ,QO
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
COMMENTS:
-
'
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)