0303-210 (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
-Professionals Code, and my License is in full force and effect.,,
License # 1 ' Lic. Class f Exp. Date
'752300 B I c-,-
C+ r'
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).
O I am exempt under Section B&P.0 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 -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 STAT FUND Policy No. - ISO=
(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 370o"of tree -Labor
Code, d shall forthwith comply with those prro�sions.
Dater ,Applicant , f✓4
Warning: Failure to secure Workers' Compensation cove rg '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 ori 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 state that the above information is
correct l agree to comply with all City, and State laws relating'to the building
construction, and hereby authorize representative of,this City to enter'upon
the above-mentioned property for inspection purposes
Signature (Owner/Agent) Date
4....� f
BUILDING PERMIT PERMIT
1
DATE ,i�fvl VALUATION LOT• TF;ACT
JOB SITE
X
ADDRESS 00 VIA NU nODIA
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
RC3�lzA�RIfS:t
i� Ate -C •Qkr�`I'hY,C:'`�Jt:1A3 co
7,3-620 VIAWLOMA
2573 MCCCARITI2OM
!A QUII,+ A CA 922:3
PAW SP11.INCTS 6k 92252
(I60)3 ). 4490 C"a3. O 6667
USE OF PPE�ERRTMIITTj
j q��•�y y��
GJ.RLCTIRM.I L7 V13JD190
440 i,..tr. b' Q . ,01 +N. V?.&L•Lg C;1TX .�► 111�U3.1FL il3h'filt+i O'Y17lffd.°4ltldd>+f.I�Y3�dCt
S kT, WALL LF'
:�I aii u9 COST fly cow, i�iUMO 61150 V0
rIti'om3'i°:ii',' is gU'i4+1.�'y . .
0aN1V'TRUC:` 1991 FU i 01-000-418,000 MAO
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MAR 2 0 : OU#'
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` CITY OF L!`--=, °DIiENTA Z
n t n FINAN'dE'DEPT _,-
902 •;IC9IAL COMMMi..l6.'" 101ST AUD PLAX C7 -TWX +tiat9
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RECEIPT
DATE; ~ %'/
BY �- -=--.-
DATf=XNALED
INSPECTO
/ ?
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
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set,Sacks
Electric Bond
Footings a-
Main Drain
Bond Beam —
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 3
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
GY.I.
S#ioke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
BY
DATE.3 —