0304-121 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed undecpn3visions 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:
ch ' License # Lic. Class Exp. Date
r1_ Date C ' ?-�� Signature of Contractor %�� • •`w "=-•-•- _----�
LIDOWNER-BUILDERDECLARATION f
I hereby affirm.under penalty of perjury that I am exemptIfrom 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 &-Pfofessionals
Code '-' "` ,
— ' 'r •'� ,
h O I am exempt under Section.
, B&P.C. for this reason
Date Signature„ of Owner
Z WORKER'S.COMPENSATION DECLARATION
I hereby affirm under/penalty of perjury one of the following declarations:
O I have and will maintain a',certificate.of consent to self -insure for workers'
compensation, as provided-for,by Section 3700ofthe. Labor Code, for, the
tperformance of the work for which this permit is issued.
,.. ( ) I have and will maintain workers' compensation insurance, as required by
'Section 3700 of the LaborjCode, for the performance,of the work for which this
permit is Issued'. My workers' compensation insurance carrier & policy no. are:
—' Camer s" � �• ;FUND Policy No. 41s
C (This section neednot be completed if the permit valuation is for $100.00 or less).
O I certifythat'iIi'the performance'oj 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
Code, °I shall forthwith comply with those'provisions.
Date: "- .x �' Applicantr., -�
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 370.6
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'hisl,v
r application. �s
1. Each person upon whose behalf this application is made & each personrat r?
whose request and for whose benefit work ii performed under.or pursua`ntto;�,
any<ptimit issued as a result of this applicaton agrees to,'& shall, indemnif'
&
an=t
of La,Quinta, its officers, agents and employee
2. Any permit`issued as a result of this application becomes null and void' i D
work is not commenced within 180 days from date of issuance of suc
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 i
correct. I agree.to comply with all City, and State laws relating to the buildin
construction,, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes. r
'Signature (Owner/Agent) f f r �`-`•- %�--+- Date
/.r
PERMIT#
BUILDING- PERMIT
_ 0 _121
DATE VALUATION LOT
TRACTJOB tJ
ADDRESS 60,51 WJ eF'AVVf!Re
APN ! i+r•� +� i:4 At'P.
OWNER•
/DESIGNER /ENINF.ER �
Ma) CAT1T1eYWffi4,Tva ,rCONTRACTOR
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USE OF PERMIT
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4'150100
MAY, 2 7 2003. }..
CITY OF LA QUINTA`. ' +t
FINANCE DEPT:' Y 14'
'RECEIPT DATE ? By // DATE D SPECTO
k}•8; •arty _ �, V v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings _
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck J
Exhaust Fans
OX 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
Drfopll - Int. Lath 7
Final
Final
BLOCKWALL APPROVALS
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`4PPROVA
Gas Test
Electric Final
Waste LinesHeater
Water Piping ,
Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection i
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:
/ ✓/ .n ��
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