0104-079 (PAT)LICENSED CONTRACTOR DECLARATION
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|hemby affirm under penalty of perjury that |omlicensed under provisions of
(commencing with Section 7OUO)ufDivision 3oxthe Business and
Professionals Code, and myLicense ioinfull force and effect.
�o uv.o/uaa Exp. Date
oaie Signature of Contractor
OWNER -BUILDER DECLARATION '
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|hemby affirm under penalty of perjury that |amexempt from the Contractor's
License Law for the following 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 (Sec. 7044i Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
6ontractors to construct*the project (Sec. 7044, Business & Professionals
( ) I am exempt under Section B&P.C. for this reason
oate��m� m Owner�~ .
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WORKER'S COMPENSATION DECLARATION
| hereby affirm undo, penalty of perjury one o/ the following uec|oouwno:
()|xavoandwill maintain acertificate cfconsent toself-insure for workers'
oomponoaUon, as provided for by Goodon 3700 o/m6,Labor Cude, for the
podh,rTian000/the work for which this permit ioissued.
() | have and will maintain workers' compensation insurance, aarequired by
Section 3700 of the Labor Code, for the pomo,munoo oxthe work for which this
permit is. issued. Myworkers' compensation insurance carrier & policy no. are:
Carrier Policy No.*
EX088P?
(This section need not becompleted xthe permit valuation isfor $1oo»ov,leao.
( ) | certify that inthe performance mthe work for which this permit ioissued,
| shall not employ any,person in any manner ooavmbecome subject mthe
workers' comp&r!;�tion laws of California, and agree that if I should become
subject' roihe workers' compensation provisions of Section 3700 of the Labor
do—je, I shall forthwith comply with those provisions.
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
o/the Labor Code, interest and attorney's fees.
IMPORTANT Application ishereby made mthe Director mBuilding and Safety.
for a permit subject' to the conditions and restrictions oat forth onhis
application.
1. Each person upon whose behalf this application is made &each'person at
whose request and for whose benefit work isperformed under mpursuant-to
any permit issued aoaresult o/this app|ioamnagrees to, & shall, indemnify
& hold harmless the City oxu^Quintu. its officers, agents and employees.
2. Any ponnh issued aaaresult cf this application becomes null and void if
work is not oommon'odwithin m
n �oo �oyo ,m date of issuance o/ such
pannit, or cessation o/wmmhb, 1oodays will subject permit mcancellation. |
|oertify that | have read this application and state that the above information io
correct. | agree tocomply with all Qty, and State laws relating tothe building
constructionj d hereby omhohzo'ep'aoontaUvoo of this City to ame, upon}
the oboVo'mentioned property for inspection purposes. /
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Signature (Owner/Agent) oate����c���
BUILDING PERMIT
DATE VALUATION LOT TRACT
Wli 01719, 19.
JOB SITE
ADDRESS
OWNER
CONTRACTOR( NEER
43-640 TECAM
1,1416. QT MTV. CA. 922MI
PALM DWERT CA 922411
USE OF PERMIT
ESTIAMITID COST 01" CONARUCnOR
2,420.60
101-000-241-000 9.50
IX=- PRE -PAID MES
MOO
APR 1 2001
CITY OF LA QUINTA
FINANCE D�pT
F1
ATE FINALED
INSPECTOR
^-—
INSPECTION RECORD
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
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
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
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)
Final
COMMENTS:
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'BUILDING�B SAFETY DEPT I
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Californla 92831 7141773-4011 o Fax. 71417;"3-1879
UNITED DURALIM Ply CTS
350 S. UwaraWam
FULLEMN 9283
FAX 0 714-773 1879
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