0103-187 (RR)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
/1"', •,
Sig
Date Si nature of Contractor
=w
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).'
() 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.
( ) 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 Policy No.
EX PT
(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 ofl, lif rnia, and gree that if I should b
subject to the workers' compen`sta idt rovlslon ection 3700 of the
Code, I shall forthwith comply with'�th0"p�p�ovis' S.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawfP,�in
shall subject an employer to criminal penalties and civil fines up to $100,
addition to the cost of compensation, damages as provided for in Sectio 3706
of the Labor Code, inte, sst and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and afety
for a permit subject to the conditions and restrictions, set forth CIA NO
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 ppplication and state that the above information is
correct. I agree to comply �thiall City, and State t�ws relating to the building
construction, and hereby aUth n F? representatives of this City to enter upon
the.above mentioned property f r msp6 ction purpos M
Signature (Owner/Agent) 2 _ Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01.01-187 TRACT
M1 t=X, 0 )AX
JOB SITE
APN
ADDRESS
'76-244 LACK)
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MW MURPHY,
FOOM? R00rW*G 00,
77� 947 LA -00 �AQefiYNTA
65w947 CtiAHOXI.A
:laAQMNTA CA 92253
DEER HM Ti?IY10 C.94k. 922
(760)288-3207 (SU
USE OF PERMIT
•,F�'.r:t0;+ lir�U �",r3�' P�.'T';{� O'I��u �t1Q8iI�'llEp S3',3'LT.Mf.��i (�.`S.�S"� ".P" l`€.1�� � s
VALUATION ;g4Sifl.i3li 'L8
E"eZaY�l1/:ATAD COST. OF C"ONMUC-p "fON
�e�i+fr83,t�65
FM20011? Fix
W �
-
MAR .2-7" 2001,,,
CITY OF LA QUINTA
FINANCE DEPT
SUB-OI4)TAL CONSTRi3t'`I` 09 AM) PLM r.MCX
$30,0
LESS PRE -PAW Fayis
$0100
r r
.t.4J.&R L A,�9KliM�lJ.�1,e7�.kr"rS.'s vE.fFs itloT7
a9r'6l
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Jfj t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
SteelAI—Ze
Roof Deck r 6
O.K. to Wrap
Combustion Air
Exhaust Fans
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
LL
BLOCKWAA64PROVALS
Final
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'
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
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)
COMMENTS: -
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