BLDG (0103-205)53305 Avenida Madero
0103-205
.,.
^ ` !
go
LICENSED CONTRACTOR DECLARATION
I,he,r9by,affirm unde-r penalty of perjury tKat I'arn'li6erised under provisions of
with Section 7000) of Division 3 of the Business and'.-',
Profession I als, Code, and my License is in full force and effect.
Lic. Class Exp. Date
I AIL
Signature of C.
-OW NER713UILDER DECLARAT ION
I hereby aff irm under penalty of perjury that I am exempt from the Contnictor's
License Law for the I ol lowing. reason:
I; as owner of the property, or my employees With wages as thei:r. sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( J 1, as owner of the property, , am exclusively contracting with licensed
Contractors to construct the project (Sec. 7044, Business A Professionals .
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'.
bombeinsation, as provided for by 'Section 3700of 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
Sdetio-n 37ob 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..
ATE TN D
(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,
1. shall not employ any -person in any manner so as to become subject to the
workers' compensation laws of California, and agree that,.if,.l should become
subject to the workers' compenghti6n Orovisions,of Section 3700 of the Labor
Cocle , I shall forthwith comply with those, ons.
Waririffig: Failure to secure Workers' Compensation coverage is unlawful and
"'shall 's-ubject an employer to criminal penalties a;4d. 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 kpplication'is hereby made to the Director of Building and Safety
for a permit subject to the Conditions and restrictions set forth i6n his
Each person upon whose behalf this application is made & each person ou
whose request and for whose benefit workis to
any permit issued aauresult ofthis opp|icomnagrees to, &axao. indemnify
& hold. harmless the City of Lo Ouima, its n#ioom, ugamaanu employees.
2. Any permit issued as'a result of this. application becomes null and void if,
*o,k is not commenced within 1e0 days from date or ioo6unco of ak'
` . pa,mit, or cessation ofwork for 1aodays will subject permit to cancellation.i'
|oartify that | have read this application and state that the above information is
correct. | agree mcomply with all City, and State laws relating tothe building
`6onstruction, And hereby authorize representatives of this City to enter upon
`m u u u
-' ~
Owner/A
.
BUILDING PERMIT'
DATE VALUATION LOi
TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER EN6 INEER /L Ji
14
USE OF PERMIT
6 FT, WAII,
1300 LF
ZRMUTED MUM COYMMU M_ ON
VNiMITRUCTION FEE 101-00041811000
]D LOU PRIL-PARD, RUM
$0,00
PERM r1X1.lP;.S TME NOW
CITY OF LA OUINTA-
FINANCE DEPT
RECEIPT
DATE
DATE FINALED
SPECTOR
'
INSPECTION RECORD
OPERATION
I DATE I
INSPECTOR
OPERATION
DATE
I 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
6_021/- O/ S'
Electric Bond
Footings
Main Drain
Bond Beam
7 - _71i _Y7
Approval to Cover
Equipment Location
Underground Electric
/ _
Final Il6 _S
PLUMBING APR/OVALS
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
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)