0103-250 (PAT)W
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LICENSED CONTRACTOR DECLARATIONKY
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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of 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
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P:C. for this reason
yti
Dated- 2 r. S Signature of Owner. i'"N
WORKER'S COMPENSATION -DECLARATION
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 performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(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, sliall 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 pr Jsions.
Date: Applicant i f
�IWarning: Failure to secure Workers' Compensation coverageLEn3706
nd
shall subject an employer to criminal penalties and civil fines up, in
addition to the cost of compensation, damages as provided for 06of the Labor Code, interest and attorney's fees. MARIMPORTANT Application is hereby made to the Director of Builetyfor, a permit subject to the conditions and restrictions sehisapplication. CITY1. Each person upon whose behalf this application is made & at FIhwhose request and for whose benefit work is performed undeo
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 inspeption,purposes.
gature (Owner/Agent).• - �s------ • Date.
BUILDING PERMIT PERMIT#.
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS E7�� 9
OWNER
CONTRACTOR/DESIGNER/EN (NEER
D,KVM ,*. ALMA CIETIVA
� w..bumm imm,
.c i �-: � claLs �),Uno
5l -265 CAUX, QUM
Gi!+.t�T:l'€AP 'd� CA 92253
LA, QXM4T !. CA, 92253
i MIN
USE OF PERMIT
10KI St;.,3 YT PA 0-10 ADMI n I;ON w ii1 ROY%OHT MON ANl:B'WOOD u AS PER
APT7#?O`J`90 `?€SAN
k'`ORC1I1YATIO 860.00 SIS
91EIMATM C OUT OF C'ONYTRUO"3HON
1, I W
� '1 Mr, a7hn
A''UAN CHUX 1W 301 _000-A 3. 9-3 18
CONSTRUCTION FRE 101-000.41-9-00D %135.0
�Y'I0jJL Yew '1.01.000.429.000 SAW
O
3 0 2001
F LA OUINTA
ANCEDEPT
f3 'IO'AAiN C 0,119TRTJt.'�.ON AM)15'.U1,IN CHEM
$252.75
'9:'O.'AL,P.F'.N,sM'.:'��'IP4'.9DE1.$+a'
$1,52.75.
RECEIPT
DACE/
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE I
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 Wail Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
UnMroundectric
Unbg. Test
Final
GPLUMBING
APPROVALSG
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:
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