0211-062 (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
7-77699 B 4/71W03
Date, �? ?'_ Signature of Contracto490+Rr�-�^s'
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 isnot 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).
O I am exmpt 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 1:I,F)��F `.i'�$ A Ikt?° A:L Policy No. 1, A262IN04727012M
(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
Code, I shall forthwith comply with, those provisions.
„Daie: _ 4, , Applicant` -1`y`- �•.
Warning: Failure to secure Workers' Cons ensation coverage is unlawful.and
shall subject an employer to criminal penalties and -civil fines up to $100,00.0, in
addition to the cost of compensation,' damages as provided for in Section 3706
Of . the Labor Code, interest and, attorney's fees.
IMPORTANT Applicafior "is,hereby made to the Director of Building and 9'afety i
.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,
uch
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 buildirig ?.
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes:`
Signature (Owner/Agent) /Aft- M'le l~ � J ��� --- Date x,/g
,
PERMIT#
BUILDING PERMIT c.
TRACT
DATE VALUATION LOT TRACT
f 5 $249003.60 11f,
JOB SITE
ADDRESS—JW6QQ Vk'..r ii�
77,2-250-011
OWNER
CONTRACTOR / DESIGNER / EN INEER
;'3„121 FRA •1�7,�Mt� Gf• 100
73-121 ��I 3 V�►,�41i it40v�1 �it'�
10AUK 1,)' �_1ix RT CA 92260
r11aNi DESERT 10A 92260
i;i E9} 3 9 r9t"s99 C;� 3C32 .
USE OF PERMIT
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PD 1,00 I IK MAGNA. 6}ZRNIT DOES 1YOT INC•LUID1 111A)CK W,A7.,L%
P400,00PAORI)RIV WA A«Pt'3k,OACH
CUSTOM CON411111111JOIT10,14 Z631100 9F
rop'OHMt A `ifi a9!r,.tl0 SP
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tS �t!ilt.4�xrr i�,At, i7r �sT+,i.2 UMM s.
CON5TRUCTION W� 1101.900-418'000 p,.05915n
Pff,KNI CHECK Frr 101-000-4.149..319 I1
MEC 1 A10CALF.Eix 1 t 1,-Qd1 42lRCi€1U 5124,150
3�t:,Irtil'fC:C' F..l i� 101-00"40-000 $41517,99
PTIU 3131'NG FU 101-000-419,000 00.41!;i,000 O1 x N,
'1TRa1OMJ H)M'FrE .REtD 101 -00S2400
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CITY OF LA QUINTA n
FINANCE DEPT.
RECEIPT *
DATE t 7 BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVA
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
1S3
Exhaust Fans
O.K. to Wrap
Q
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
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 APP OVAL
Waste Lines 1 �� _
Water Piping
Gas Test
Electric Final
Heater Final
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
Notice
I 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
Utilfir Notice (Perm)
COMMENTS: