0102-115 (BLCK)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
M1.3 112
Date ?w /3-- 44 Signature of Contractors
OWNER -BUILDER DECLARATION 1 -�
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
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:
Cartier Policy No.
STA 9 FUND 124"990-09
(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 Secti(: rh,3700 of the Labor
,Code, I shall forthwith comply with those provision
Date: t / sY.,.+�e Applicant—
Warning:
r^ -• `, .
Warning: Failure to secure Workers' Compensation co rage 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 PERM T#
DATE VALUATION LOT TRACT
TRACT
s1«.1 M ALY1 IUI i
JOB SITE
APN
ADDRESS
2-3_M AVMMA 42DRECYON
773-254-017
OWNER
CONTRACTOR/DESIGNER/EN INEER
PAAC OC MAD;fa S COM"FUCT),014
1?r' MAC `IMUn CONSTCRI.Yt.'"l ON '
1719 a Tim, M0N'T
1719 37IRMA I A
3 OCEANSIDE CA 92034
S CA. 92054
(760)961.R0069 03.1.9 3 915
USE OF PERMIT
OM. iW. ,. B Z.IUIi O
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3 FT. WAIA, 1DD LF
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CONSTRUCTION FEE 101.000 118-M
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RECEIPT
DATE, �;BY
DATE ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS f
Set Backs
Underground Ducts !
Forms & Footings
Ducts i
Slab Grade
Return Air [
Steel
Combustion Air
Roof Deck
Exhaust Fans [
O.K. to Wrap
F.A.U. ` E
Framing
Compressor {
Insulation
Vents
Fireplace P.L.
Grills ;
Fireplace T.O.
Fans & Controls l
Party Wall Insulation
Condensate Lines t
Party Wall Firewall
{
Exterior Lath
[
Drywall - Int. Lath
t
4
l
Final [
Final
BLOCKWALL APPROVALS
POOLS - SPAS 1
steel t
Set Backs
Footings
Bond BeamLp%®l
/� c�7
(
S7
Electric Bond [
Main Drain }
Approval to Cover
Equipment Location f
Underground Electric i
Final
_
5'j'j o! ✓�
Underground Plbg. Test {
Gas Piping [
PLUMBING APPROVALS
Gas Test {
Electric Final [
Waste Lines
Heater Final I
Water Piping
Plumbing -Final I
Plumbing Top Out
Equipment Enclosure [
Shower Pans
O.K. for Finish Plaster [
Sewer Lateral
Pool Cover I
Sewer Connection
Encapsulation [
Gas Piping
f
Gas Test
[
Appliances
I
Final [
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)
COMMENTS:
Certificate of Occupancy
This.Certificate issued pursuantto the requirements of`Section .�09"of .the flniform Bui/ding Code,
certifying that, of the. time o f issuance, this structure was -in comp/lance ' with' the various ordinances
of.:the' City regu/a#ing ,bui/ding construction or use For the fo/%wing: {
BUIWING AD'DRESS:- 52'=3,75 AVENIDA:;OBREG_ON
Classificateon: -SFD :Bldg. Permit No : :0012-06:1
Occupancy Group. R 3 Type of'Constructiori: VN Land Use Zone: RC_
Owner'of Building:- PACIFIC`TRADES,CO
:NSTRUCTION: Address: 17.1:9'S. TREIVION.T-
City: S. OCEANSIDE,. CA 92054
By: STEVE TRAXEL
Date: 05-07-01f
Building Official
POST IN A CONSPICUOUS PLACE