RER (0307-313)76943 Calle Mazatlan
0307-313
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LICENSED CONTRACTOR DECLARATION .p
I hereby affirm under penalty of perjury that I am licensed under provisions of
PUtMIT#
BUILDING. PERMIT
Chapter 9 (commencing with Section 7000) of Divi§ion 3 of the Business.and
DATE t r•VALUATION ( LOT: TRACT.
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Professionals Code, and my License is in full force and effect.
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License # • Lic. Class ,r Exp. Date
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rDat .j `^ Signature of Contracto •/vl_ e " "~
OWNER
CONTRACTOR /DESIGNER /EN 1N+EER
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OWNER -BUILDER DECLARATION/
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I hereby affirm under penalty of perjury that I am exempt from the. Contractor's
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License Law for the following reason:
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( ) 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).
USE of PERMIT
( ) 1; as owner of the property, am exclusively contracting with licensed
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contractors to 'construct the project (Sec. .7044, Business &- Professionals
Code)..
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O •1 am.exempt under Section B&P.C. for this reasonLO "
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Date Signature of Owner
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, . WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one, of the following declarations:
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O J.have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the. Labor Code, for the
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performance of the work for which this permit is issued.,' '
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( ) I have and will maintain workers' compensation Insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
workers' carrier-& are:
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permit is issued. My compensation insurance policy no.
<' 'x .` E Ff,3a .Ey Policy No. ' 3 4 ;x3 36 3afs+ . '
A "«Y °t}'! ". +,C '.",'3iN OF IIAX$11'12 $11'12 78.1`It 3'{ I l'
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(This section need not be completed if the permif"valuation is for $100.00 orJess).
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O I certify.that in the performance of the work for which this peimit is issued;
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I shall not employ:any person -in any manner so as to become subject to the I
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workers' compensation laws of California, and,agree that if I should become
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subject to tlhe workers' compensation prov slops oLSectlon 3700 of the Labor.
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Code, I sh 1 fo • Wit comply with arose , ovisro
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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
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addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
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IMPORTANT Application is hereby made to the Director of Building and Safety
for, a pe'* subject to the conditions and' restrictions set forth
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application.f.
1. Each person'upon whose behalf this application is made & each person at
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whose request and for whose benefit work is performed underor pursuant to
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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.
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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
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permit, or cessation of work for 180 days will subject permit to cancellation'..JUL
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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
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C onstruction, and hereby, authorize' representativesfof this City to enter -upon
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the above-mentioned property for„ inspeldtiompurposes.'
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RECEIPT;
DATE 1 .r BY_
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INSPECTOR
Signature (Owner/Agent) f"e o ' r i Date
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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 APPROVALS
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 5 —
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:
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Ofinson (Development Inc.
CUSTOM HOMES AND RENOVATIONS
WK# (760) 7734. 7
KEITH D BRINSON CELL#(7601 50AQ1 00,
Fax#(760)779 0- OIL r
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Brinson (Development Inc.
CUSTOM HOMES AND RENOVATIONS
WK# (760) 7734487
KEITH D BRINSON CELL# (760) 409-3506
Fax# (760) 779 0488
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