0312-151 (RR)49745 Anacapa Cir
0312-151
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
8105W C39 Ric V3),404
Signature of Contractor J
r .
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 Codc, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier $IuIPWYER OCCUPA Policy No. OI MB06-1003
(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.
,Daie: ' t 1, - Applicant IN, _
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. I
Signature (Owner/Agent). / Date
,BUILDING PERMIT PERMIT#
DATE ...ww— VALUATION LOT TRACT
P.1
XVII 431,104.00
JOB SITE
APN
ADDRESS 4.9-74.3 (. NACAPA CMCLLP
._
OWNER
CONTRACTOR / DESIGNER / EN (NEER
9 CRLrE,KVIMIt RD
83900 AV .G.k;rdE 4a, .5LIFIT, D
CCyf0 DE CIS CIS
=110 CA 92201
(760),200.0811 C1:11.4 1420
USE OF PERMIT
(1M?? ' ALBUT1I'DWq,
ft&ROOP STR11CTU1,12K (2 ADD iZfrMES- 94/45 &49-751 AifACAM) Wi 1111
CUBA MATOWAL9
VWIV ja.T ION 11,104.00 V
C:C7 ►'.ior CON'si' t MON
.11,10 4.00
y. 77, j t app r .l Ni°:11 A.'dM
Pa*.a,M3;r 87 d 11 gul".1iiRY
REROOF FM 103.000-41 R-000 30.11G
DEC 16 2003
(CITFYINOAN
I
F LAQUINTACE DEPT.
MR -TOTAL L GCI `'3`1`It.T.1G 01,114 AND 1"'.i.tkiv* C'°MEC1,9
$30.00
LES'..) PT' - VAM PLAS
$0,00
IIIIIIIIIIIIIIIIIIIIIIIII 73
RECEIPT- ,. 'r
DATE
1 i
BY / I
DATE FINALED
INSPECTOR
/Ii, J 5
I JNT
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 AJO,l ly
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
Pond Beam
Approval to Cover
Equipment Location
Underground Electric
:
Underground Pibg. Test
-sinal
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
%Vaste 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:
0
i
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)