0107-166 (RR)• JY
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty.of perjury that I am licensed under provisions of
0hapter.9 (commencing with Section 7000) of Division 3 of the Business and
P�ofessionals Code, and my License is in full force and effect.
License #Lic. Class Exp. Date`
Date "7,12'ZiQ— Signature of Contractor
I hereby affirm under penalty of perjury that lam 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` &4 policy no. are:
Carrier Policy No. 0,
(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 t!106 provisions'^
Date: ^► Applicant 1_Of�f3- • a �a
Warning7Failure to -secure Workers' Compnsation.,c_q'e rrage is unlawful and
shall subject an employer to criminal penalti s and civil.Jtnes up to $100,000,: in
addition to the cost of compensation, damages as provided for Iri Section 3706
of the Labor Code Interest and attorney's fees.0
IMPORTANT Application is hereby made to the Director of Buil did g 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 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. p
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 .ofsuch
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 compyxwith all City, and State laws relating to the building
construction, and hereb'yauthorize representatives of this City to enter upon
the above-mentioned property forIr; pectiot3.•plposes. ,:•'
r.'biyndtur01,lowilyllAyel,tlf, F� d a. Det `7 71. � n
.: 'BUILDING PERMIT PERMIT# /
DATE � VALUATION LOT
yVA Qit,Z� d��� TRACT
JOB Srf9
ADDRESS
APN
113-•2111: ` 91W1 rA. .T)X .A OPAL
_
OWNER
CONTRACTOR/DESIGNER/EN (NEER
.a
LR GURA DE LA MU10A
WE51TIM PAMIC IC RO0M. 0
PO M. X°r01
314621ACAIAMIAWAT
pvRX0.10 IYdp E CA 92270
AYeUyWRMW CA 722.62
(760)41&5877 C' ILO 4293
USE OF PERMIT
Etl?� '�3hR CTC 1111110 00,1''4630 • POkXC►RMTKA' E FOAM &ACRT14C
�`,,OAT03 ROW111303YSTFM
E111STOMMED COUr OF C. Jim
2993MI
�'R:�.(a�` r t.A�U�L`�4�3'A,�1 -y �
fr LA M�
JUL 23 2001 1t4�'�{
ti
RECEIPT
DATE /
BY
1.DATE FINALED
INSPECTOR
f I
,•ti_w,r-
s.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
Combustion Air. ,
Exhaust Fans
O.K. 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
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond;F.am
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I 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 Test
Appliances
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)