0106-120 (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 # Lic. Class Exp. Date
r . �
Date 1,�.^ Pry / Signature of Contractor"/l 1 a '
M~OWNER-BUILDER DECLARATION
I hereby affirm'under penalty of perjury that I am exempt from the Contractor's
License Law for rhe following reason:
( k) .l, 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).
( j I, as Ownet 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 work for which this permit is issued.
• "a II�� , ave 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.
(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
,,, Xode j,shall forthwith comply -with those,provisions.
Date.''`r� s Applicant ,A'3 i Z,
r
"Warning Failure to secure Workers' Compensaon 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 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/6f this City to enter upon
the above-mentioned property for inspection purposes
Signature (Owner/Agent)�I ! f r _._' .^a•R .rC Date.% r
BUILDING PERMIT PERMIT
`4.
DATE VALUATION LOT �A� �r�9y�i�i TRACT
`'1
JOB SITE {,,,, _•..
ADDRESS
"r.-a!,•v� ..K.wK`n
APN
^Y 7'�i.6 f�fA V.4 � /�� Y � � �—+V O
CMS. .�.131CiMY Mb
OWNER
CONTRACTOR / DESIGNER / EN INEER
'A 7480 X 17111 ST. 01 06
17489,11- IMI Ff. 01(A5 .
"T°faa3 CA 92,780
T05TW 912780
.(,A
014)508-4440 MLR,
4485
USE OF PERMIT
WALL all:: 46L?4' GA;,,'RD.RX 81,t;WX"tAi'AL,1-,.ORCO
UMARD,
6 IPL WALL R7.00 LF
4 irr, =Kai L I F
.14wro"'m con OF colvaimanoli
2,911,00
PERMIT P�."IR UNARY
*
LEW PRB-PALD TOM
—�_4.
P
$0,00
"M= EMS DUE NOW
J U L 2 6
X4,00
2001
CITY OF LA QUINTA
FINANCE DEPT ,
RECEIPT .
T31
BY
DAT FI LED
INSPECTOR. `'.
Mr
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
Condensatelines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS'
steel
Set Backs
Electric Bond
Footings
rond Beam tv/i
Main Drain -
Approval to Cover
Equipment Location
r _
Underground Electric
-al rLiT9,�
Underground Plbg. Test
Gas Piping
PLUMBING [[[[Af�PROVALS
Gas Test
Electric Final
;te Lines
Heater Final
1A �r Piping
Plumbing Final
Piwabing 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
Temp. Use of Power
`
Final
Utility Notice (Perm)