0308-346 (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
Signature of Contractor
OWNER -BUILDER DEO ARATION
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).
( ) 1, 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 work for which this permit is issued. .
(k;) 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 & Qolicy, no. are:
Carrier i.;P?i'i`I'1' )dl:i7't3�,.1r Policy No. YdA3$?YEl4>y�30t'�''I.
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(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of We work for which thls permit is issued,
I shall not employ any person in any manner so as to become subject to the
w(?rkers' compensation laws of California'
al1nd agree that if I should become
subject to the workers' compensation provisions of/Section 3700 of the Labor
Code, I shall forthwith comply with thosq,,provisio�nix. - �a 1
App\icant , a J_.. I rjf ..✓
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
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 u er or pur t to
any permit issued as a result of this applicaton agrees to, & shall, in i
& hold harmless the City of La Quinta, its officers, agents and e s.
2. Any permit issued as a result of this application becomes null an i if
work is not commenced within 180 days from date of issuance o u h
permit
,.or cessation of work for 180 days will subject permit to cance lati
I certify that I have read this application and state that the above inform ion is. C
correct. I agree to comply with all City, and State laws relating to the ti ildin
construction, and hereby authorize representatives bf this City to enter upon
the above-mentioned property for inspectron purpo;/es.
Signature (Owner/Agent) �ate
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BUILDING PERMIT PERM'e;}«Y
DATE VALUATIOND� LOT K TRACTJOB
SITE
.ADDRESS fif110W SIA YAGIUROS .
APN 7'sr�«�•�rC
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MIX lWf, TFR- .>wq; Wr'
Tm L wl o;'F_FRS kme -
i o fI' 0 .
CA 92260
CY6G"i)1 4.9699 }}.31A -3832
USE OF.PERMIT
SWRY 7RKW'iX Dvnaj,.:NCI
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isUCIt ,I WALIA POOL
CU00M CnNUI!'+r()CA-1,1g0N D.363.0 8P-
150:1 CH/1-1A.Ti'0 : 558.00 SY
0.+1I AOFIC<AMx' ' OP
CONSTRUCTION ITS 101-000-4118-000, %1,4",00
PLAN f","1 a,; X I fs: 101,-J4043M1R �►,tQ�1.63
r, F.:Q`'H AN IC' AL, Pa,.iE. 101-00Q-4211 ^17f�0
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ART 'IN PUBLIC PLKUS -11.001". 270 -000A45 -OC -0 00.46
AND
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UN PME-TAMP te,
Q-4 2003. TUYA L IA: .AUT YNX,S DUE, N0W
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TY OF LA QUINTA
FINAPICE DEPT.
RECEIPT
DATE 9
BY it .
DAT FINAL D
INSPECTOR
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
Fireplace P.L.
_
''
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWAd
AP ROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBINGP
OV
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
Final
Utility Notice (Gas)
ELECTRICAL
Temp. Power Pole
Underground Conduitor
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)
APPROVALS
COMMENTS: