0109-168 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Sectiol, 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
"IWti'W C11119 BIC, '11130/2(
Date Signature of Contractor
OWNER -BUILDER DECLARATION
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).
(k/) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exelnpt under Section , B&P.C. for this reason /i
Date r .. rpLJ % Signature of Owner �/ir It / h�,� V
t
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 Pollcy No. "
(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 those provisions..
Date: 61V.1u r/`�, Applicant—f
. ,.r . .� L vi.�i,✓
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 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; indemnity
& 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 authorize representatives of this Citylo enter upon
the above-mentioned property for inspectjon purpose §,
Signature (Owner/Agent) ��';�,� -/` Date
BUILDING PERMIT PERMIT# ,
DATE VALUATION LOT . TRACT
SRSiLladd� "`ti
JOB SITE
APN
ADDRESS Q�►q g/ {�y �+
OWNER
CONTRACTOR / DESIGNER / ENGINEER
RwrMG,twa
P101211OX. ) 0610
83- 7.0 a' °�' ax°1',
7 : ia" E43 10A
=10 CA 92201
(760)-e,47-9669 OWL 5978
USE OF PERMIT
CJ`[-.�,���53%i•.Hf�ie�M,.r! 61P:rp,�P••wY� '
VALAIATION 1,30% Do L's
lyrn-wrDw uUmMARY
E A00Y, M. F, 101.000-41&000
- r c
DA
SEP 18 2001
A
CITY LA
OF QUINTA
FINANCE DEPTIMS
9
IM. -PAID M�4
Tan.t "atwr FEE'S DUE A OW
&40100
RECEIPT
DATE}'
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
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 I Fnramtdatinn
Final
COMMENTS:
Final/ /dIA// 4V
Utility Notice (Gas) /yd'
ELECTRICAL APPROVALS
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
J