9801-031 (SFD)• LICENSED CONTRACTOR DECLARATION
il 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 f6ll force and effect.
License # Lic. Class Exp: baite'
7
71 - 0,
b
Vu ate-- t- Signature of Contract r
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 .- -
1, as owner of the property, or my employees with wages as their SO11'e
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) . 1, as owner of'the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &.Professionals
Code). .." t. . . . .
O I am exempt under Section —, B&P.C. for this reason
Date Signature of Owner"
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-insu re 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:
CarrierPolicy No.
S17KI'L714ND 117100015U
(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'9_ec_ti`on-3700 of the Labor
-ode, 1shallf?ft on
forthwith comply with those provisis.
A ,
Date: Applicant—
Warning: Failure to secure Workers' Compensation coverag6.is unlawful and
Shall subject an employer to criminal penaltieeand 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 it 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 thii 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-, "Iand State laws relating to the building.
N
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspectionipurobses.
'/Signature (Owner/Agent) Datel/.'i, ' x lli4
- PERMIT #" CONTROL#
BUILDING PERMIT
DATE VALUATION s2 saik . LOT'31TRACT
JOB SITE kAPN
ADDRESS 7.S-91 5 'd IA CA �L
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ME, IT
I�R Ks c
0.0. BOX 17i6
102 .05 IRAINCHULA QUrt4TA DR -
A. _922-5,A
LAQUfNITArA
LA %11hr CA. -92253
(-1r1tl1T7k-f. At. C8L# 2996
USE OF PERMIT
L017,i 1, PACAZIO 1"LAN'-1 ..'Akr INPUBLICIPILACES �.F26ff 0#.,
M2,00,PEK AQ F W/ C01MK X)Fl D hPT,P liAN CTf liCkl Fe.7,
PA I Dap
JAN 1
5 1998
croN -i coN�uzur_=N 3.031.00
33100 sr
OAtAGIRICARPORT
*`CITY OF Lk
OUNTA
11�&11XATUD C IT OF M
PE,Rfkiff FUU-SUMIJIM.NRY
P 101-600-439-348
CONSTRUCTION.F76;
11
AE'(2A NICAL Flaa! 401-00014-:000
5v!1RONG NfCIT10-NJztF, - F_173!1,)
_P NO '101-OM4213-000- ;00
MWRASTRUCTUkF3 Mi 225-000-443-3421 X5:537. 2
YRrI0 SE Pf.,A.N 101-000-441'145°
33131-00
T
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%1Jt-TCVrAL.C,'QNSTR, TIION-t1NDPLAN,CHEGK
147 9418.71
YkE. PA- "C' 174�
LESS I ID Us
43R,100
01 V "PORMIT F-UP-SDUE NOW.
A
RECEIPT
DATE
BY
DATE FINALIED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs -I -
Underground Ducts
Forms & Footings - El
Ducts
Slab Grade 3=� Q/
Return Air
Steel _ (/j�
Combustion Air
G3
_
Roof Deck - -
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing -
Compressor
_
Insulation - Z- xac
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
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
OX for Finish Plaster
Sewer Lateral _
Sewer Connection L < �_
Pool Cover
Encapsulation
Gas Piping 3
_
Gas Test -`G!
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
L
Final
Utility Notice (Perm) R� /