0002-239 (BLCK)LICENSED ONTRACTORy
DECLARATION
11 h,4r; , 6;9;iffi& under penalty of. perjury that I am licensed under provisions 6'f'4-�'
pter 9 11 (co - mmencing with Section 7000) of Division 3 of the Business.and
Professionals Code, and my Li6ense'is in full force and effect.
-'License # -.2. . Lic. Class Exp. Date
is cik�€i .Al "A' 06/30;20(
Vate /7- Alignature of Contractor'
OWNER -BUILDER, D , ECLARATION
I hereby affirm under.pen6lty of perjury thit I am exempt from the Contractor's
License Law for the followih g reason:-,.
1, 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 --I (Sec. 7044, Business &.Professionals Code).
) 1, as owner of the property, am exclusively contracting withlicense'd
contractors to construct the project -(Se6. 7044, B6siness & 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 penaltyofperjury 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 foi which this permit isissu',edf.
I have and will ;maintain workers' compensation, . insurance, as required by
Sgcfibn 3706 of the L'abbr.Cocle,'for the performance,of the work. for . which this
permit is issued. My workers" compensation insurance carrier & policy no. are:
Carrier„
arrier Policy No.
ARCON'Mil
(This section "neednot be completed if the permit valuati6n,is for $100.00 or le . ss).
I certify that in the performance of thework for which this permit is issued,
I shiIll.not employ any peirson.in any -manner so as to become subject to the
workers' compensation laWs of California,.4nd agree that if I should become
subject to the workers' cior"Kpensation',pirovisionsof Section 3700 of theLabor
Code, I shall forthwith comply With those provisions.
I .
")Applicant!
vDatte: 6'
Warning: Failure to secure WorkersCompensation coverage is unlawful and
shall subject an employef to criminal penaities'and civil fines up to $100,000, in
addition to the cost of compensation, -damages damagesasprovided 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
fora .1 a
permit subjeLct to the conditions nd.,'restrictions .,set forth on his
application.
1. Each perso . n upo'n Wh 6se 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, or cessation of; work for 180 days will subject permit to cancellation.
I certify that I h6ve 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 herebye
. authorize repres. htatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (OwnerMgbnt)`AI' .4 .14D �,�- J
ate
BUILDING PERMIT PER MIT#
DATE VALUATION I . , LOT TRACT
JOB SITE
ADDRESS 49-3-00 NPIKFA M NOPAL 7
r
OWNER
CONTRACTOR DESIGNER / ENGINEER
LAGUINUk INS LA PAZ.HOA
V,Ik L I �.M T�\”, t�, -, F, Co M-1 I., �!I,- •-
d18 VISTA. D.ENOPAL
32776 ROSECRANS Sof.'3RD 1'10OR
].,A Qwqnk. CA, 92253
19ANDIEGO CA 92110
(1i19')24_5 x1/97 .1530
USE OF PERMIT
0 R N U R-ALDWIL UN 6
22 LIT, 641 GARDEN WALt Q.1TV STANDARD (TkAX-1 ENQLIOSL
6 1, WkLL 2240 .L
ESTIMAITE0 MST of, CONISTRI110C N
'TM
550AW,
P&RINUT FEIR SUMNfluty .
C�ONSTRUGMON FEW-' 101 -WO -418,M0 $1 Tof)
sup.-Tariv, CONSTRUCTONAND P1,AP CHECK
L PRE 8
ESS. 1,PAIDTIM
$01-901
T0'1F1AL,PCR1\1JT VMS DITF,'NOW
"s ru
RECEIPT
DATE
BY'
DATE FINALED
INSPECTOR
7 T
INSPECTION RECORD
i" OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Insulation
Compressor
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
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 0 QqC9
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
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: