0209-173 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm -under penalty of perjury that I am licensed under provisions of
12 $ Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel w Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date +
Z; 0 10di513U3 B 0127 C53 07/31/2(
�LLJ�
cZ Date ?� Signature of Contractor-'�—
O�
Hc J OWNER -BUILDER DECLARATION
U
-� C.), CD
HaW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z"( ) 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).
Cl) () I am exempt under Section , B&P.C..for this reason
LO
N Date Signature of Owner
O (V
O)
CL Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W u- compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m QU have and will maintain workers' compensation insurance, as required by
O U Q Set)ion 3700 of the Labor Code, for the performance of the work for which this
U-) H permit is issued. My workers' compensation insurance carrier & policy no. are:.
v Z Carver S') MA : Fl,)'k+ D Policy No. 1680, 88
CIS "i
g (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 l should become
3 _subject to the workers' compensation.provisions-of=Section-3700-of-the-L-abor-
Code, I shall forthwith comply with those provislons.,`
../Date:�ADDlicant- ' 1
Warningi Failure to4secure 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 3700,1
of the Labor Code, Interest and attorney's fees,
IMPORTANT Application is hereby made to the Dlrector of Building and Safe'ty k
for a permit subject to the conditions and restrictions set fortN �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,
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 i
correct. I agree to comply`with all City, and State laws relating to the building';
construction, and hereby authorize representatives of this City to entor upon
tl� above-mentioned property foririspection purposes.
Signature (Owner/Agent) /-' Date L2
BUILDING PERMIT PERMIT#
DATE VALUATION ���3.Qf LOT TRACT
r1,2f•4,Y• ,
JOB SITE
ADDRESSa^•n�. aC r T+Y?�
APN m
OWNER
CONTRACTOR/DESIGNER/EN INEER
MA1�MULITS It�a:1C31�/CI�1�T:#TjR VA:X 1
VO D SITYf '.i CT'i.�,S C,'C�c�s'ia~tE1x.'�.t{��1
$1.2251 1"l`113W(3NIMATH
41555 "P19CCALME
I.AQM+1T11. CA 92253
BYA'tA1MMIA,IYUN1,.A, CA 92201
C,160)',3604400 MILO '3046
USE OF PERMIT
POO" I., AVIDJOR .3PA.
S3tw3&YJi.,aSPA. ALARAWS.&MUERS SHA:L3„.02, 14 Pi ACY AT PP&p'I,&ITE
POO.Ie R` N VIO SPAS. 19,UDis.DD IS
rIdMINI.) COSOF CCN511KI rkovL
.�K;aFgTF0'fWh2# TZS
PLAN CHECK ECK ISE 101"000_439.31 CS $121-11. 12#0
CO NSTRUMION P72 101-000.4.18-000 $198.00
MECHANICAL MU,._MOL, 101.000k421-000 $241100
GCI:>ds$4.5.00
,PT.liMbl"Nc1n1^': - POOL 101 000-419-000
p a '9i�Y i - MAL t - T �K fflJC7ff01\TAM FLAK C -EMC
:422.70
L1153 PRE -PAM FEMIS
$01M
SEP 2 e 2002°SAL
��E�1:��t1MS IXTA .SOV/
S42200
CITY OF LA QUINTA
FINANCE DEPT. ,
RECEIPT -1
DATE1+
BY < �
I D ✓
I PECT
Z-1
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
Set Backs
steel
Electric Bond
POOLS - SPAS
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
r
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
�7—
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.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Final
COMMENTS:
V, _ -
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