0201-087 (BLDG)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
Professionals Code, and my License is in full force and effect. .
License # Lic. Class Exp. Date
7-p 1,5 ,{{313 Yro3
Date ' Signature of Contractor—
OWNER-BUILDER
ontractor
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
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
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.
STATF< BUND M601 UNIT4009,1 I d;
(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 become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sha I.fortith comply witgtho p provisions. /;
Date: '% r: ' '-- Applicant , `, '. . L I I / i
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, indemnify
& hold harmless the City of La Quints, 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. 1 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. /1 /
Signature (Owner/Agent) ' , i, ( / % �Date i ° ' ° •�•
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0201.007 TRACT
JOB SITE�1 / ^
ADDRESS J Cly
APN
k ttd@S'i'��7I3: CJJ(
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OWNER
CONTRACTOR / DESIGNER / EN (NEER
1' Q3A A''F.MP`�7' 17014
DEL lailAR PACM0 CM40RAL i �O'r!TR AC."1 C ,
350 i3CtX1 t})r,0
2533 30171M C+7N37111011WAY MB 250
Lk QWN7<A CA
CAkD1P.1+' BY YW' SEA CA 07,017
USE OF PERMIT
MIS.MI T I .AkdL"OIJ 3
B UILt"1NO 30 - Sri -807, 54•$29, i4 -RSI, 3A-571 'liOLtlN X'A.RY
3TRUC:T1IR.A.1. id ODIFWA'I'ION'.1,
VAIAI.ATION NOW. Do 1,114
FSII I'.N"D COSI' OF CC3NSIRUMION
?U,i100.(1ia
3'F1ktRR3''I'b' E SUMMARY
('CYNSTRUCTIO)II FEE 101-000-415.000 3=00
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STRONG MOTIGN h%F • RPSID 101>Ot! -341-000 $2.00
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RECEIPT
DATE
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DATE NAL�D
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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
Root 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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVA S
steel
Set Backs
Electric Bond r
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping o
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 Plzster
Sewer Lateral
Pool Cover
Sever 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
4 Main Service
Sub Panels
Exterior Receptacles
j G.F.I.
' Smoke Detectors
Temp. Use of Power
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x Final
Utility Notice (Perm)
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DAVE STEAVENS
Inspection Services
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the. reported work, unless otherwise noted,
substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
104he locations of the work inspected only and does not constitute engineering opinion or project control.
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CERT. NO. ?c� �� t 1/6 -
INSPECTOR
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CERTIFICATION OF COMPLIANCE: To the best of'our knowledge, all of the reported work, unless otherwise noted, , r
substantia] complies with approved plans, specifications and applicable sections of the building codes. This report covers' '?
,b hof the work inspected only and does not constitute engineering opinion or project control. 1=
CERT. NO.1 INSPECTOR NAME S J C. S -f& A J C W 45
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CERTIFICATION OF COMPLIANCE: To the best of'our knowledge, all of the reported work, unless otherwise noted, , r
substantia] complies with approved plans, specifications and applicable sections of the building codes. This report covers' '?
,b hof the work inspected only and does not constitute engineering opinion or project control. 1=
CERT. NO.1 INSPECTOR NAME S J C. S -f& A J C W 45
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DATE Ly 2yu7 INSPECTOR SIGNATURE �� iO.r.A. ,4
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