RR (9705-134)77127 Calle Mazatlan
9705-134
'DECLARAfION
UCENSE113,CONTRACTOR
I hereby affirm under penalty of perjuey:that I am licensed under provisions of
Chapter § (commencing with Section 7 . 000) of Division 3 of'the Business And
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
.2357 17
C-39
/Date Signature of
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of,perjyry that I am exempt from the Contractor's
License Law for the following reason:
1, 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
Code).
sale (Sec: 70 ' 44, Business & Professionals
1, as owner of the property,- am exclusively contracting. with licen . sed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section- B&P.C'.-'for this reason
Date 'Signature of ,Owner
WORKER'S COMPENSATION DECLARATION
].hereby affirm -under penalty: of, perjury one of the. following declarations;
have and will maintain a certificate of consent to, self -insure for workers'
Compensation, as provided for'15y, Section 3700 of the Labor CoclO,Jor the
.,performance of the work for which, this permit is issued.
0 d
I have and will maintainworkers' compensation insurance, as require y
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. P64 NO.
STAT8FUND
omis A46
(This section need not be completed, if the permit, valuation is for $100.00 or -less);
O I certify that in the perfoirmanceof.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 Califdrhia,-'And agree that if l.'should become
Isybject to the Workers' compensation provisions -of Section 3700 of the Labor
Code, I -shall, forth, Iith comply with those "'p .o_Gisions-
/6ate: .2' 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.6s provided for in Section 3706
of the Lab&'Code, interest and attorney's fees.
IMPORTANT Application is hereby mBide*6 the Director of.801clin g -and . Safety
for a permit subject to the, conditions and restrictions set forth on', his
application: -
1. Each person upon whose behalf this applicati6n is made & each pers6n:at
whose request and for whose benefit work is performed under or puF.suant,to
any permit issued as,a result of this applicaton agrees to, & shall, inblemnify;.
& hold harmless the City of La Quinfa, its.officers, agents and employees.;;'
2. Any rpermit issued as a result of this application becomes null and void if V
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 t ' he above inform.ation.is
correct. V agree to comply with all City, and State laws relating'to the. building
construction, and hereby authorize representativesfof. this City-toenter upon
the/above-mentioned property for inspeAtion purposes.
,
/signature (Owner/Agent) V Date
PERMIT# CONTROL# -v
BUILDING PERMIT 1
97055-134 5221
DATE VALUATION. LOT TRACT -
JOB SITE
ADDRESS
77-127 CAL.44XA4AZA1*1- N
OWNER- CONTRACTOR DESIGNER ENGINEER
t,rL;,k!1t-,. p,% r I-V (;)C)Fj'N
-0 I rNKINROWER-OR 3462 LA. CAMPARAWAV
'P.A. M.'SPRIN(IS CA 9220
11. .41 QJ19f.A. CA. 'CVW5_ I -
-60?2 COLY 42W
USE OF PERMIT,
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ADNIX .17-1271,12,91131 ( AUJ! MAYKMAN
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VICKIMI S OU K, N 0 $30.00,
[RECEIPT• y ]DATEBY' DATE FINALED INSPECTOR
1
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 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:
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