0106-264 (RPL)LICENSED CONTRACTOR DECLARATION v
I hereby affirm under penalty of perjury that Cam 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 \J 4F
OWNEWBUILDER 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
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 wof'k for which this permit is issued. -
W• I have and will maintain workers' compensatlon insurance, as required by
Seed 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:
Cartier Policy No. .
STATE.H`UND x�-9fl-flC193
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 ag1r7ee that if I should become
subject to the workers' compensation proyisions of,Section 3700 of the Labor
Code, I shall forthwith comply with those p1ovlslons. ..•• �
Date: Applicant % �• \. -�
,,y Warning' Failure to'secure Workers' Compensation coverage is LIN a f nd
shall subject an employer to criminal penalties and civil fines up to $1 [inaddition to the cost of compensation,.damages as provided for in Se n 3of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building nd Safor a permit subject to the conditions and restrictions set fo h on
application.
1. Each person upon whose behalf this application is made & ea42erson 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: 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 inspectiohkpurposes.
Signature (Owner/Agent) �`Nk 1N- . Date IT
PERMIT #
BUILDING PERMIT
DATE {/ // VALUATION LOT 0106.264 TRACT
$1510*040 13
JOB SITE "`wh, _' "r
APN
ADDRESS
OWNER
CONTRACTORDESIGNER EN IINEER
+n8 %OrylT.yPlW
W2YACpA�ION Vryy-THAVf1Y
ft
9522lkiil; 1.u)e.
(760)24G.-6045 (MI,4 4335
USE PERMIT
yryOyy��Fy ¢q�
u'dd�3 3p.Ft,.AlCaAPMY93APtjZRS! Sil.MA, 89 IN F°IACF•AT PR'&P .a %. T[fR
,TPP�i KX,'T3t,)-K 1001, EQUI xUTNT EXCIAMR11 HOT 1H(%,1. JW -,1).
11001,,MWOR VA. 1fJLGDfl 4ti LIS
' AN—n" R'J.A. Y1D C0.17h' Or, MR47�.1e.R'L41CJ1J.0
15,O D.00
PW&N CHUCK Me �000-43,Q-318
CONI f' UCTION FZE 101-000-418-000 $1i3 .flU
I?X,W,TR.it.;AL FEE — POOL, 28??-t2r�a dl�i3-Ot�tti �4�'i.@X?1
PILUNKRMCI "A — "t OL. 101 d00" 1 MOID
AY 2 5 2001
ITY OF LA OUINTA
FINANCE DEPT `
59 AA:.d°CaWMRUVl'ft)9 AND PLAN C`RECK
$363.30
IM03 PRY -PAIMPRES
S0,00
- P
WTAL PE"YEVELKS WE NOW
1361210
4
RECEIPT
DATfEj/J�
BYDATES
FI`NALED
INSPECTOR
'r.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel i
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
rT
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
ElectricFinal
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
`G[F.I.
Smoke Detectors
TQ. Use of Power
Final
'Utility Notice (Perm)