BLDG (0001-067)77560 Calle Madrid
0001-067
Y -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
399424
Date Signature of Contractor - =
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).
( ) 1, 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:
Carrier Policy No. ' .
3TX'1 i3-FLIND'
-V, P9 0 2113811
(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
11
work fs' compensation laws of California, and. agree that if I should become
sub 1'ect :to the workers' compensation_ Rrovisions o Section 3700 of the Labor
C, d'e, I shall forthwith comply with those provisions.
tDate: ' ' .6Applicant f 12
Warning: Failure to' secure Workers' Compensation coverage, is unlawful and
shall subject an employer.to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages -as provided for in Section 3706
of the Labor Code, interest and.attorney's fees. _
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions, and restrictions set forth on his
application. i
1. Each person upon whose behalf this application is made & each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applioaton.agrees to, & shall; indemnify
& hold harmless the City of La Quinta,'its:officers, agents and employees.
2. Any permit issued. as -a result.of this application becomes, null and void if
work is. not commenced within 180 days from date, of issuance of such
permit, or'cessat'ion of work for;180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
Correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorizerepresentative`s of this.City to enter upon
=_(Owrier/Agent).
mentioned property for inspection purposes.` % i` Date `f
BUILDIG PERMIT PERMIT#
_N_
DATE 0%f$./a()0VALUATION "II LOT. TRACT
JOB SITE
ADDRESS 77-560 C.ALLF, ..I6)
OWNER_
CONTRACTOR /DESIGNER /ENGINEER
ULj.AAV011. sqNNO*01"v.
'RAL C1xN:Vrii,t it`:ra.i.iSi,',, aC ,
"842 11ER4.1OSIL LO ilii
4.1 $tDS .BOARD"vV,rtL , SUrIV .1:12
C.'-.Kf"HlDPLAt. c".:frf CA 92234
P AL,M.€7ESF'2Tr CA. 922
(160>340-4445 CBL# _"03
USE OF PERMIT
17C:.fVIE.",F(AL Bia'1;,IANG
l;MWI N WALLS - 1W LIZ, yu, ; cN 801..'fr. (4 4°, CIV STA.tvT3.AWD _
S Fr. . IVALL 100.00 ilk`
4 FT WALL 80.t")(! .LV
>b .l kt L A iPJ V''i!' A .Yl LV/1 n 'iA♦6ll Y.. A-.5i1.!'.f el
" r.9Xg.}
CON-Y[RUCT10N Fa 101-000-418-000 $63.00
i tla= i'raMA9; Ct;►f(`LK'?ONtf;1VI-ASI C'! if
I.ps taut►":-PA.fl7 FEE 3
'.rOIAY;, D'E:SZM3.`.8' FE..&S DUENOW
S03-00,
RECEIPT
DATE
BY '
DATE FINALED
INSPECTOR -
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel.
Set Backs?
Footings
Electric Bond
Main Drain
Bond Beam
7
Approval to Cover
l?l
Equipment Location
Underground Electric
Final3 /p0 S%
PLUMBING APPROVALS
Underground Plbg. Test
Gas Piping
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
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: