0301-077 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury thatl 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
X 40' ' X3 MCIW311103
Date C� . y ' 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
"Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
1 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.
.Ir 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 .�TATE TJ1, Jb , Policy No. 046-73,39.203
(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�l should become
subject to the workers' compensation,provisions"of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. ,� -�
Date:' r, ->� % Applicant ` a;, `' .
r
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
,additionJto 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 statethat 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. r'
Sig'nature_(Owner/Agent)1 Date's f a?
BUILDING PERMIT PERMITN
DATE ` VALUATION LOTTRACT
t�2 6 S351,38830 22
JOB SITE
ADDRESS 49-WWA. 60NQUI.S IAPO.LO
APN
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OWNE,Ry
CONTRypA�CpTOyR;/ DESIGNER I EE(N 1NEER
(�E.(
LX J...I.G.A.C.�1:�1 1J�'tl�Nafe�1X"i�.ial'dY .L
iP'.l`4aCCi� L"6..'.1`44.13'�.T�.IIJ"•�'f.dl;4
F0 BOX 17 If,
1-295 T` AMO L:fA �Un TfA DIL
LA QUWA CA. 922S3
LA. Q 'NIZA CA 92253
USE OF PERMIT
rl,1D •, LOTS 2.2; PLAN MSR PERMIT It OFS,'XfXr 114CLUDE BLOC
WAJJJ,� PtX)4 SPA'Of,, DWY -E 'WAY APPROACH, 75% REDUCTION TO
P ,KM C;HZCK ;t'LE DUE T0 .E+t}.UVf-1V E 1SWANCE l� F SAW9 PLMI TYPR
IUSTOM 00,14 T`1'A17CTION 4,243.00 SP
f3 C'iir :t.'PId�3a00 sip
K11WAAGrUC.�RPORT 17,10,00 By
,
.
D C6101 OF C01tiuIt fi ucX1011
yFlu,JmdArE
'1 5� 101 0-41�i 00 $:l0-439-318
y /y{--/0�In �y,��Brl�..�t!
y �Iypk�ITllUter' FEY,71
NZ
MEC IMINit" 'me 101,000421-000 313iP;5f3
PI:UMBIN'O FE 101-S 00.419-001 670&00
STRO;i O MOTION MEP R331ID 101.000-241-630 $33.14
103-000-4234XIO $15.00
1DP1VZ PE,'lt:1114PACT FBE $2,05.00
1 IN fi'UBLIC! P,. tM - RESIT TIO -000-145-000 V70:47
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S'U'B-'CtaTAL CC T. of :u 1'rG ' MID PIAN ClMl M
ry
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TDATE—
RECEIPT Fo,
BY
DATE FI LED
INSPECTOR
W
w k�
••. _r ,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
3 • ` • V 3
Ducts
Slab Grade
_/,z -100
Return Air
Steel
• (o • O 3 /
Combustion Air
Roof Deck
- a
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
s
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
_
U- — 3
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 �,
�j/�
Heater Final
Water Piping_
�{
Plumbing Final
Plumbing Top Out
✓
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
2_ / �—
Encapsulation
Gas Piping
Gas Test
- A
,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)
-