0108-364 (AR)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 Exp. Date
•g '� l 7, 6,r�
Date Signature of Contracto. ;/�_/
- 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).
( ) 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
r BUILDING PERMIT PERMIT"
DATE ! I / VALUATION LOT 27 tTRiM-'�t' 4 TRACT
JOB SITE •' APN
ADDRESS
ax -too SCF.f�'C:��"t`1��}':k�(.E#,�' vt 76749t'�- '7
OWNER CONTRACTOR/DESIGNER/EN INEER
PAUM, D&SHWIr CA. 92260
USE OF PERMIT
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
piqtf4rmance of the work for which this permit is issued.
//�� ave and will maintain workers' compensation insurance, as required by
`action 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.
(This section need not be completed'if the permit valuation is for $100.00 or less).
- . (-)-I-certify,that-in-th'e-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, a�,{�d agree that if I should become
subject to the wo kers' compensationVe.;Fns
tion 3700 of the Labor
Codebt f� fo ith comply with tho
Date: Applicant
""Warning Failure to secure Workers' Compensation coverage is unlawful and
shall subiect an emplover 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 resul,6of 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 authorize representati eb of this City to enter upon
the;above-mentioned property for inspection r oses.
Is
wli`?'r.fue A9 `f .
TOLL RM7'ii3i RS 300
74-923 HOV.i L-Y.:ANF �:T RITMIZ-220
PAIM. D.WWRT CA 92260
C760)6-74-9699 Mif 3832
TO PERMIT 00103-301, sA D D'IND 317 S.F. C-ASI`.i'A I'D
WD MHU, WK0195. CX>t S'T1Kt1C'PION (;WTANA).-15%PLANCf M—K R}?
10.3ri CTilr; N FOR. Pvi'f.Xi."i. iSSI.fANCE OF SAM9 PLAN.
.. CIeMOM CtD'AtS`i'R"t1`CTJO?N 3.!'9.UD OF
PA.i R'Mrf V Ve WWWARY
MEOIRNHICAL
li UC°1i RIM, L IE.I,
Sf°d' OWO Rv OTION Rrssd)
p
,,. .; rwu pf�� RECEIPT
Signature (Owner/Agent) � , 0 ' Date_ : ; :.
SEP 0 6 2001 I I
7-1
FINANCE DEPT. i
LY °! . C
NMR CY10Ai' AND PL A.�1�,i' �t�"ik�WA?t�M, �1��ry��(J $217.3n'(�j
f
TOTAL PU MU FEES DUE NOW
9
a
DATE , BY DATE FINALED INSPECTOR
1.01 <000-42'ii-Wo
;!101-000-420-000
8 3.Oa
101-000419aLY�0
570.00
SEP 0 6 2001 I I
7-1
FINANCE DEPT. i
LY °! . C
NMR CY10Ai' AND PL A.�1�,i' �t�"ik�WA?t�M, �1��ry��(J $217.3n'(�j
f
TOTAL PU MU FEES DUE NOW
9
a
DATE , BY DATE 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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final Lr "moi_'% � W U
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX 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)