RR (9705-139)76903 Calle Mazatlan
9705-139
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LICENSED CONTRACTOR DECLARATION
I hereby affirm of I,am licensed under provisions of
PERMIT# r' CONTROL#
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PERMIT
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under penalty perjury.that
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9 -(commencing Chapter in with Section 7000 of Division.3 of the Business and
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Professionals Code, and my License is in full force and effect.
DATE VALUATION LOT TRACT
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License # Lic. Class Exp. Date
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SITE
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OWNER
CONTRACTOR/DESIGNER/ENGINEER
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' ` •Signature of ContractorG - F' ” ' % -
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OWNER -BUILDER DECLARATION '
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I hereby affirm under penalty of'perjury•that I am exempt from the Contractors
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License Law for the following reason:
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( ) .' 1, as owner of the property, or my employees with wages as their sole
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compensation, wl o t e wor , an t e s ruc ure no en a oro e . or
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 F1 i7. Jle TG
Code). s
ce)() I am, exempt under, Section B&P:C. for this reason tt i F ;fOt^it t't3i.`k'ir12 1:{T1iN .'t CJI A ±'c, ikCR '%1C COATING i Al 1'3•(itai AU. A3
LO -'N Date Signature of Owner gNL%r, `76i 902V8931883/i373 QAJ. L; , 1AjA LPLN
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- Q WORKER'S COMPENSATION DECLARATIONCL
`O Q 1 hereby.affirm under penalty.of perjury''one of the, following. declarations: c
O•. O. 1 have and -will maintain a certificate of'consent to self -insure for workers'. Vlia,At.[.C3dT;
;,x Wcompensation, as provided for by Section 37.00 of the Labor. Code, for the
m, _J _J< performance of the work for which this permit is issued.
QU ( ) I have and will maintain workers' compensation insurance; as, required- by
O U. Q Section 3700 of the Labor.Code; for the performance of the work for which this t ,
Il U' H permit is issued.. My workers' cornpensation insurance carrier'&•policy -no. are:
? Z Carrier r Policy No:
crD O SI'rSti;'1 UJe13 . :11afiG t •ir:: ESTUA'Is,°0;' "ti ', 5'I O :ON'S' 'R. rSs9"tl -N
J (This section need not be completed if the permit valuation is for $100.00 or less): 'ira mi"'r rem vA1. [ i itv
O I certify that in the performance of the work for which this permit is Issued, 1<# ftoC+ft F MRa.ffl-f){iA.t {)f9{} $3t?,GF1
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
S biect to the workers' compensation provisions of Section,3700 of the Labor
/ode, 1 -shall forthwith comply with those,.provisions.
ate: •'a ,r 2 Applicant
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 ori 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 s r }s vyL f t j {A rCQJ i riT1t'1 A1N:9'.(14N e"'( 11 r'h
&"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 ( `' 1'l i T'1j6
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. r' i' r • -
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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:. (,t
e above-mentioned property for inspection purposes. •' / - e,
RECEIPT DATE' BY j DATE FINALED IN
Signature (Owner/Agent)
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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
BLOCKWALL A ROVALS
POOLS - SPAS
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
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: