0211-046 (SFD)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
711699
bak-te Signature of Contracto
OWNER -BUILDER DECLA vi"CON
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: -1
( ) 1, 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).
1, as owner of the_pr6pgrty, am exclusively contracting with licensed
contractors to construct the ,project (Sec. 7044, Business & Professionals
Code)
O I am exempt under Section J 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.
'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 MBERTY MUTUAVY. Policy No. WM88 004174012TI
(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,
l.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 -Jo the workers' compensation provisions of Section 3700 of the Labor
Code;. I h 11 f hwifh comply with those provisions.
' ;:p,,,all to3t
Date: 44 - _ - , P
4�i 4 Applicant
Warning: Failure to secure Workers' ComVensation 'coverage is unlawful and
shall.sUibj ct an employer to criminal penalties and 'civil fines up to $100,000, in
addition to' the cost of'co'mpensation, damages as provided'for.inSection 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 applic.aton'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 6pplidation 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 informatio, In 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- meritioned prop6riy for inspection purposes.,
Signature (Owner/Agent) Datel4iA,
BUILDING "PERMIT PERMIT #
DATE VALUATION LOT TRACT
30357
JOB §ItEAPN
ADDRESS J� 772-2=494
OWNER CONTRACTOR/DESIGNER/EN (NEER
TOIL BRUTOW.WC , - BROT-IMLI ivC,
11), 00 73-12.1 MM WAR'W9 0100
RAt! RX CA $rWO PAWDY!'(3-KV
OA 92,260
(10)674460, ME* 36714
ISE OF PERMIT
Ift 'UDY6 .`i.ANTOUXA-0. Or.
WAUA POOL� SPA ORDRIVEW
MAYAPPROA-10H
CUOTOM ('014MUCTION I
00 X7
PORCHIPATIO T ;Isrho 1�
XV20ATED COF)r OYCOMMUTCMION
Pkim, TFX71 OMMARY
C008MUCTION FEL
1011-000111416.000
$1,29.1.30
PLAN CHECKFXF,
-000-439M318
MECHANICA1, FEre,
101 -000-421 -000
$119100
EWTIUCAL M"P,
101-000-4.20-000
PL -U!' FEE
1 01 - 000-4 1 9i*00
STRONO MOT1014 FFZ - RZ.MV
101-000-241-000
ORADINO M
01 -000-4,Aq-000
3 15. W
DEVEWP r, It W PACT I IFT,
2.,4 V.S. oo
AM' IN PUBUC VIA07,49 - WIE'270100.0-445-000
85
vt
WM-TOTAL C0NW.,Rk1TC. OR AVID PlMf CTWXX
n
S 1
,5,419,94
MOO
14 5,479AA
PTY DUN NOW
NOV I
CITY OF LA QUij4TA
FINANCE DEPT,
t.
RECEIPT DATE PY DA FINAL INS FECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION.
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings p
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
F.A.U.
Compressor
/
O.K. to Wrap
Framing
Insulation_
Vents
_
Fireplace P.L. -
Grills
_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath C>T
Final
BLOCKWA� L APPRO ALS
inal
_
-
POOL SPAS
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
Waste Lines O
Gas Test
Electric Final
Heater Final
Water Piping r�
Plumbing Top Out
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sever Lateral
Pool Cover
Sewer Connection e d S
Encapsulation
Gas Piping _
Gas Test _ �✓
Appliances / • V=
Final
COMMENTS:
Final
Utility Notice (Gas) a
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit _
Rough Wiring
Low Voltage Wiring
Fixtures !
Main Service
Sub Panels
Exterior Receptacles r—
G.F.I.
Smoke Detectors
Temp. Use of Power
Final - - —
Utility Notice (Perm) I
i