0312-208 (MISC) LICENSED CONTRACTOR DECLARATION PERMIT# or
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
309
H (commencing Chapter 9 in with Section 7000 of Division 3 of the Business and ' ��-
p ( g ) DATE „� r` VALUATION LOT TRACT
c*4 LLUU Professionals Code,and my License is in full force and effect. '” l Fl�t:� � ►�
O d M License# Lic.Class Exp.Date
JOB SITE
W 640342 B 613104 ADDRESS -M- 01 kV?.1JF:46 APN
rZ r, Date f'' f`� Signature of Contractor ' '�'� ��^ '� ----'' OWNER CONTRACTOR/DESIGNER/EN INEER
O OWNER-BUILDER DECLARATION �'�RC�'"�"�1''�'VC0 INC, 'c`�M CO MIMIIj'�L�.CIAL.BUILDER S NC
J U � 2920&CAMDUZACI;;IZOAD ME 100 1300 R`51M`30i.`IM AVE
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's , ,,
a Ff1())E [3,. AZ 1850,r 6 PHO1124M AZ £5014
License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole (602)263-8300 t<TLfp TBD
compensation,will do the work, and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Cf) Code). TEMP.CONSTRUCTIO14'TRAILM, PER M-UP t 03.44; D A
LO () I am exempt under Section B&P.C.for this reason
O N Date Signature of Owner
rn
Ua Q WORKER'S COMPENSATION DECLARATION
It Com.' z I hereby affirm under penalty of perjury one of the following declarations: { r t.
CC
'i�.�LU.ATION 1, O,�,Cy)ws
U*) FQ O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' �' CITY F LA QUINTA
X LLj LL compensation, as provided for by Section 3700 of the Labor Code, for the FIN%NCE DEPT.
O J Q performance of the work for which this permit is issued.
m Q IJ (") I have and will maintain workers'compensation insurance,as required by r
QSection 3700 of the Labor Code, for the performance of the work for which this ►
U
fl rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
v z Carrier VALLEY FOR,09 Policy No. C1031341=4 n. Dlli?[AME COQ:`OI,C0I15FRUMONC3 M&M YEE WMEKARY
t.�s,f3E70,i�U
J (This.section need not be completed if the permit valuation is for$100.00 or less). MAP CONSTRUCTION TffWIM 101-000.423.000 1200.00
( ) 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
3 subject to the workers' compensation provisions of Section.3700 of the Labor
Code, I shall forthwith comply with those provisions,.-/
Date: �^ ''---`��: Applicant ►""'r"',' G'-,rY' `�
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. 4
1. Each person upon whose behalf this application is made&each person at SUI3_TOTM,CONSTRit'MC'N At-TD PLAN CHF C?TC $200.00
whose request and for whose benefit work is performed under or pursuant to LIES.3 PRE-PAID PEES $0,00
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 TO`IAL PF-11,4 ITY7TS IXTE NOW 5200.00
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 IIIIIIIIIIIIIIIIIIIIIIIII
• correct. I agree to comply with all City, and State laws relating to the building 53
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned property for inspection purposes.
' �+�--- RECEIPT DA�TE� / BY INALED INSPECTOR
,Signature (Owner/Agent) d Date r
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
Firr I 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)
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)