0111-238 (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• F_ p. Date
f9 07 1,�2
Dated " r�/� Signature of Contrac r �.
OWNER -BUILDER DECLARATION � I.
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:
STAT9 FORD
(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 is
I, shall not employ any person in. any manner so as to become subject to the
I..
compensa Ion laws of Califomi& and agree that^ifi, I should become
subject to the'worrs' compensation provisions of Section G700 of the Labor
Code I shall forthwith comply,with those provisions
Date: tf t : �d , ;` Applicant: fir -
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 of
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 and 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'i a representatives of this City -to enter upon
the above-mentioned property for iii tibe purposes. j'
S7 ! y,:
Signature ;(Owner/Agent)`"Date
BUILDING PERMIT PERM T#
DATE / VALUATION LOT ryy �A1i� A^
TRACT
y
2945
JOB SITE
ADDRESS
il^'2,�'?Sd;tWrw'.Jl,
APN
6419 -''
OWNER
CONTRACTOR/DESIGNER/EN (NEER
MOM. 17 16
79-295RANCHO Lh QUWA DR
I,.AQuD11A CA 92253
I.AQI1WA
'CA 47,253
4`^i +5C1 ' 1 1:141
C'T I.d 2996
USE OF PERMIT
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PW, 4;TPA ORDRIM7AYAIPt1RCiACT
tvWASP
laprygey��p;xaa:sr:�ig�
t?td4. ir'�L2 dam" s' P0�7'�' 693.00 9F.
01:95 011 !�'i ANMI 7C` 8 f£.�:R
}� j� �y+g+y p�� gp�* T,�g`�F'��.�t;AM
P.M
PLAN C HFICK.KI 1011-00043,9-318 $2164.23
.
ir-C ANICAL t. U 101-000,421-000 �B4f�.Sta
MWY'i°ltICAI:.1T:ff 101.000-42-0.000
VI.fIIMDANO RIC 101-000-419-000 8:di12,
STRONOMOTION 1fFL,t P 01D 101-000-241-070
101-000-42 4-000 $20.001
Fy
p p � L ¢ 2
AU IN Pt1S>v,?C PJAC ..RR 31E X10.01 0 445.000 $201TY
{mil u.' aS t lr t'�„1 '6' '. iE`:7CIG x �'c��3 ''_��.�JIi$J• 4"1r IC1Z
-.,? t •1.`s4J
:MS IME -PAID TWOMWIT
U, irJ
Fa* VOL
DEC 06 2001
CI UFLAQUINTA
RECEIPT t'.
D/ATE�
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs y— 1g- Z
Underground Ducts
_
Forms & Footings Z, _
Ducts
Slab Grade y— ZTI--
Return Air
Steel .y —
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap_
F.A.U.
Framing 0�,
Compressor
_
Insulation Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath V/ .
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
_
Waste Lines
Electric Final
Heater Final
Water Piping _ —
Plumbing Final
Plumbing Top Out b '�
Equipment Enclosure
Shower Pans _ _
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection y — y . ZS
Encapsulation
Gas Piping
_
Gas Test
Appliances el -
Final
COMMENTS:
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)