Loading...
9703-025 (PLBG)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 GN Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penaltof.perjur.e y that I amxempt from the" yContractor'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). s ( ), I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business &Professionals Code). O 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 performarice of the work for. which this permit is issued. My workers' compensation insurance.carrier & policy no. are: Carrier Policy No.' ' 907—POV01r Grp' PILL-' ( his 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 Californiay, and agree that if.l� should become subject to thie w rkers' compensation ov�f nsof Sectionn.3700 of the Labor ode, I s a' I f hwlth comply with those pp- ovlslons. /�.-" VID ate:, Applicant Warning: Failure to secure Workers' Compensation cov'e/rap 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, indemniwy,. & 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,insp/ecctt onpurposes. Si nature (Owner/Agent) '1 �--+/ - ' Date � �- /A? • - BUILDING PERMIT'" PERMIT - CONTROL# - 9703-025 4777 9 DATE VALUATION LOT; TRACT ,3/ 6/y7213.oa) . . JOB SITE ADDRESS >20A%`1r:Ni.C1f���I!:D1Y APN OWNER CONTRACTOR/DESIGNER/ENGINEER ,:a„ TOM .r i�f t tliAi. _ ^r.?�iT.a ti ri s )t":IE T 54220 AL'.la`� IDA' 08R>~GON 1347 WL BOX 1, A (,'t.1.€Pm" 1"A. CA 9223 ' VIC1110KNIRI .> l:.A 9M7,% - ', •. (G49;Y;',='`�4�t+'��tl . • . �13I,# 3ty'�:1 . USE OF PERMIT 8i�:iri�r113 WIN, ACV, �i+A r u� k!I•�xr.FFit . . ay XS ':O C� NS111. ��C ION. �.:��a.f�� y yy� C SUMMARY. flt+0��') p.�9. 3.'-.6:+.x'1 7�.i.I1�d.lY�Y:J1R �iy. .. .. t.t�N8'nifj0'10N FE 1©1-0)0-`i18-000 P1:<t.�A�ii:�WO 11:C is i (14-f)tlt1-<1 �.'�-!X>t? $7.50 ' y . LESS 1'`t:l-t�.All) lel fs"";� $0.00'a . �. P�st� TO Aga MOR � lu ��Xi DUE twc�� xzx, �. 51997 •: • � . �IECEIPT BY DATE FINALED INSPECTOR ' �DAT GRY V1 d..-— 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 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 Appliances Final COMMENTS: Final Utility Notice (Gas) ELECTRIC L PPROVALS 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)