0107-107 (MISC)LICENSED CONTRACTOR DECLARATION
I hereby affirm underlpenalty 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
71,519 ;s
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).
( ) 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&RC. for this reason
Date Signature of Owner
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 I Policy.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 �,� at if I should become
subject to the workers' compensation �pr visionsebf Scctiory37,00°of the Labor
Code, I shal fort �v'th comply with those provision
Date: ° APPlicant-x�'i'�£'_.. .
Warnira :Failure to secure Workers' ompensation coverage Is unlawful an
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, 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 representatiVes�Of this City to enter upon
the above -mentioned Drooerl:06 "inspection oufrpl es..% / J
BUILDING PERMIT PERMIT#
DATE �. VALUATION LOT 0107-107 TRACT
—) / ! f e' tJ SAM
JOB SITE "^ APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
1.k Q airrAI•r't w—L X v DROOXWO ME `ice COO WC
�9019)6544,4414
USE OF PERMIT
SUP;PC.AME1+5?AL- ` O PPR M YJ' 0205.1 V TO RF MEC d` Ef.,iCTi2gK:,f4i.• .FIVIiS
1=2"17D COST OF CO SIMC".';"J 0,11 0.00
XU T RICAL 1172- 101A000-4,%t-0o0 $107," ,
LESS PRE -PAID FM3
J U L 1 1 2001
t
RECEIPT DATE"')' `� By DATE FINALED JINSPECTOR
Signature (Owner/Agent 4141, 4V " Date
y 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 -
Drywall - 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
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas. Test
COMMENTS:
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)