0101-258 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirmunder penalty of perjury that I am licensed under provisions of
1;) `~Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cal W Professionals Code, and my License is in full force and effect.
C =) M License # Lie, Class Exp. Date
r` d Lo
oZ r1_ Date — Signature of Contractor
0
J U OWNER -BUILDER DECLARATION
F-
LU LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
co () I am exempt under Section , B&RC. for this reason
u7
N Date Signature of Owner
O CV -
0)
Z WORKER'S COMPENSATION DECLARATION
o 0� I hereby affirm under penalty of perjury one of the following declarations:
r FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q pormance of the work for which this permit is issued.
coQ U ) I have and will maintain workers' compensation insurance, as required by
O tJ Q Section 3700 of the Labor Code, for the performance of the work for which this
d w F— permit is issued. My workers' compensation insurance carrier & policy no. are:
"t Z Carrier ( h S Policy No.
STATE
Jy7 1
J(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: --7 Applicant
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, 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 property for inspection purposes.
Signature (Owner/Agent) Date. -
BUILDING PERMIT PERMIT#
+
DATE i _ r VALUATION LOT 0101-2n, TRACT
JOB SITE APN
ADDRESS
80 1 } V p
OWNER
CONTRACTOR/DESIGNER/EN INEER
tvi At A�dt +3i3
RICK. .3C:�••r,,'(140014 E�'i: M � ."PI"[J0TWX 4KII.
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C.A 12253
k '6jTR_A01 � C-1A 922VO
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USE OF P�E`RMIT
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11003 .f., V, 611 Ol1.k'L" KtN WALL r4.' :,VT L.F. 41H CIA N,[ IE3d WA c
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JAN 2 4- 2001
aa �,ppy� r I
RECEIPT
DAtEl
V
DA IN 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 Firewail
Exterior Lath
❑rvv.,all - Int. Lath
Final
Set Backs 1 _I
Footings
Bond Beam
OPERATION DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines 1
Final
Steel
Electric Bond
Main Drain
Aooroyal to Cover
Equipment Location
Underaround Electric
POOLS m SPAS
Final ��j]��0�—l//( Gas Piping J
—4�
;,a F" �l�r 3 -��� aa,, �,r� Gas Test
b:1 `, 4'N 'OV `� Electric Final
Waste Lines 1 Heater final
Wate- Piping J Plumbing Final
Plumbing Top Out j Equipment Enclosure
Shower Pans li i O.K. for Finish Plaster
Sewer Lateral _ Pool Cover
Sever Connection Encapsulation
Gas Piping
Gas Test
Appliances I
Final I
r COMMENTS:
Notice
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power I
Dec 16 02 11:51a
p.2
CITY OF LA QUIHTA
�, 95KL G & SAFETY DEPARTMENT
t"`� 777-701 2
� . V', NSPECTlON REQUEST UNE
777-7153
Ow NUSSBAUM
rIBC
Contractor HICK rOl-INSON CONSTRUCTION
Permit Number 010I-258
POST ON .JOB IN CONSPICUOUS; PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRESS 80-940 VISTA GAIAPE
I -op L.F. 61H GARDEN WALL &37 L.F. 4'I1 GARDEN WALL&
10L.F.5'11 GARDEN WALL (POOL EQUIP ENCLC SURE) - CM
STANDARD
F
TYPE OF INSPECTION
DATE
INSP.'
FOUNDATION & SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING
PRE -GUN ITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN
CONCRETE SLAB
SIGNED
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
nn unr DnI IR r`n NCRFTF UNTIL ALL ABOVt HA5 bLLrV SIGrvtU
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
HEATING & VENT -A/C
FIREPLACE
ROOF
l
BOND BEAM
O.K. TO WRAP
GROUT. ❑ W ❑ 9
FRAMI NG
INSULATION
PRE -ROOF
rn�co wn WARI[ IINTIL ABOVE HAS BEEN SIGNED
DRYWALL INTERIOR
EXTERIOR LATH
POOL PREP k5TER
POOL FENCE & GATE
SEWER SEPTIC TANK
I
FINALS,
ELECTRICAL
'
PLUMBING
R NAL GAS TEST
HEATING - A/C
HOUSE NUMBEfiS�
JOB COMPLETED
TEMP POWER