0103-143 (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
Date '�+. -- ~ /�Signature of Contractor -1,
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
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.
STATE FUND i'!>�t57�4a�Ot1
(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 PApplicant–
Warning:
pplicant Warning: Failure to secure Work -ars' COmpensatlon coverage is unlawful and
shall subject an employer to criminal penal4ib' and civil fines up to $100,000,-4n
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 &,}eachVpe son at
whose request and for whose benefit work is performed unde'r 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-mentiot '!'J property for inspection purposes.
Signature (Owher/Agent) Date • % E I
BUILDING PERMIT
PERMIT#
DATE VALUATION LOT
0.1,0.1ra,43
TRACT '
001' I&M 9", IS
5
BX. K 1891.1.10
JOB SITE
APN
ADDRESS
15 AMA OBIREGO
V 1M
7744,14-015
OWNER
CONTRACTOR /DESIGNER / EN (NEER
PACC11IC'. Tkt a:I.).E IS C:Otr1'SMUCI I014
PACMC; I.TtAD Z CO:i SM.RUCTION
1719 S TIMMONT
) 17 19 81 ryndoyrr
8 OCEANSIDE C.A. 92054
8 OCla..AZ<P (D ,
CA 92054
('760)967.0069
Mif 1.955
USE OF PERMIT
CSF-14)RAL WEA.nING
Z3 LF T f:AitL8,E`rt. WALL
:23 LF 9' C1.AF@IJM WALL
BO'T'H C1TiC'STA1g1).A.P13
5 Fri , 'WALL
2100 Lit'
4 FE WA111-1
23.00 LF
ESTRVAJ?tTM (.100 ` 011' C01'iMUMO
50. 9,'5
FE RW, f FEE allhWARY
€'OAiSTRUC'I'If32N FU 101 -000-418.000 $63.00
MAR 2 0 2001 -"
t176 '.t'Ci'11'•I, COINIMMY MDU AND JPLA. CM CK
$25..00
TOTAL PM :kl* ItTES DIVE NOW
RECEIPT
DATE/ /
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings I
Ducts
Slab Grade ,
Return Air 3
Steel 1
Combustion Air
Roof Deck I
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing i
Compressor
Insulation 1
Vents
Fireplace P.L. }
Grills
Fireplace T.O. !
Fans & Controls
Party Wall Insulation I
Condensate Lines
Party Wall Firewall }
Exterior Lath I
Drywall - Int. Lath i
I
I
Final
Final I '
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs i (
Footings I 7'a 5
Electric Bond
Main Drain
Bond Beam 1
Approval to Cover
Equipment Location
I
Underground Electric
1
Underground Plbg. Test
Final }
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines I
Heater Final
Water Piping 1
Plumbing Final
Plumbing Top Out i
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral I
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping ;
Gas Test 1
Appliances I
I
Final
COMMENTS:
'•
j
Final
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit I
Rough Wiring I
Low Voltage Wiring !
Fixtures I
Main Service I
Sub Panels I
Exterior Receptacles I
G.F.I.
Smoke Detectors I
Temp. Use of Power
I
1
Final i
Utility Notice (Perm) i