0112-111 (BLCK)} �",, "'IL'ICENSED CONTRACTOR DECLARATION
I herPhy`afflrm,under penalty,of,perjury that ham licensed, under provisions of
0"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 # a ' Lic. Class Exp. Date
i ..
'704270 C29
Signature of Contractor
' OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from tfirContractor's
License Law for the following reason: :' t
( ); 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.exclusi4ely contracting with. licensed
contractors to construct• the project (Sec. 7044, Business & Professionals.
Code).
( )- I am exempt under Sectionfi' 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:
( )• l 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
Secf°on 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:
CarrieriNDRMNI T'Y• %W3, Policy No. N" i>r Il l i •ptJ
.:(This section need not be completed if the per valuation is for $100.00 or. less).
O I certify that in, the performance of the workfor which this permit is issued, v
a I shall not employ any person in any manner/so as to become subject to the t
`Workers' compensation laws of California,ad agree that if I should become €
subject to the workers' compensation/prov,Isions of Section 3700 of the Labor
Code; !I hall forthwith comply with those provision;
.,Applicant—
Warning:
,Applicant Warning: Failure to secure Workers' Compensati
shall subject an employer to criminal penalties and
addition to the cost of compensation, damages as
of the Labor Code, interest and attorney's fees.
Ige is unlawful and
up to $100,000, in
for in Section 3706
IMPORTANT Application is hereby made to the Director of Building and Safety
fora permit subject to. the conditions and restrictions set forth on his
application.
1. Each person upon whosebehalf 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 application aAnd state that the above information is
correct. I agree to.comply with all City�`,and State laws relating to the building
construction`, and hereby author•Iiz�fepresentatives of this City to enter upon
Ili—
the above=mentioned property foMpspection purposes.
Sig stare (OWner/Agent)' '` -"r �• Datw -6—
PERMIT #
BUILDING'PERMIT ti
DATE "'� EVALUATION .LOT' . �� �y - TRACT
} ry p@ 9
�.:bAAill�blY{.r ti �a�..��'JN79 lCii/.4fi�8 _ �._.g��•
JOB'SITE .r. !
APN
ADDRESS ' '810-1V FDWA GR&M.Y-t.' ~
`'OWNER - '
CONTRACTOR / DESIGNER / ENGINEER
YYaat yy.�j, fi. •� p��y
.���l�iY S .Al�]A^IM �IYC
1 S3 Y���J;S..T. Jl. t•'1.�P. iL v7.l!L••,
80-2 60 uUWA GRA.°MS'
.
72:72 VIA. VAIL
C 11 CA 922;3
"RA C:KOTAIR GE C•l. 92270
("76o)250n8253 CRLY 3£3
USE OF PERMIT,
GIAIFFRA .. Will -DIN,
36' 1JPX s' Am bi' COMBO R E'!"a" I-Ai`�iC�` l�.tt�S�,,'�',.t�A 'tiff's LIJI ;
122 1,F 61(1�,' WA.t✓'
RDJ1 BO L 2'^Tl,.•83N!'EM Y:'.FII I A"' OR00'',
S°Arw7;3r�r1 E.
6 FT, INA LL 148AILF
EYMATI.'I'i CCPS7 (YO' CfT:i NYVIIRITMION
3,700.00
T? ,f2ci 3rnw wmwzy
-
n�r. 1 2001 j
e�11MOF LAF QUINT.. /w
C,
r
RECEIPT
DATE
By
DATE-FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall 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 I
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 fest
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low -Voltage Wiring
Fudures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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