BLDG (9705-133)77181 Calle Mazatlan
9705-133
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1. 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
235717
/Date Signature of Contr aetor
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). . , ' - . .. r
( ) I, as owner of the property,'am exclusively contracting with licensed
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 *Own er
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.
ct( ) 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.
1 'FU 045762446,-
i(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
workers' compensation laws of California, andagree that if I should become
ubject to the workers' compensation provision.s of Section 3700 of the Labor
Code, I shall forthwith comply with those provlslons.
Date: ' 'r . Applicant—
Warning:
pplicant / d
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.
1. Each person upon whose behalf this application is made & each person at
whose request and;for.;whose benefit work is performed under •or:pursuanifo
any permit issued as a result of this applica ton agrees to, &;shall, indemnrfy
& 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 cessation 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 authorize representatives of this City to enter upon
t I above- mentioned property for inspectlon,purposes.
Signature (Owner/Agent), 4 =-- - Date = f
BUILDING. PERMIT PERMIT# w; , .; CONTROL# ";, -
-
970543. 52' :
DATEVALUATION LOT, TRACT
JOB SITE
qpN
ADDRESS 17 181. ( d LUE MAZAT LA
OWNER
CONTRACTOR / DESIGNER / ENGINEER
S .AiT 1110SA COVE -1-10A.
49 -mo ; aE t iG; i2.'.IJI
3461 LA cp:AMi•'A:NA. WAY
LA QC..f'WA CRA, 922,53
PALM .SPRINGS ripe. -42 26
40-6022
01 19"
,
USE OF PERMIT
t k CtiUtr fyC i.l•.%'f1I2 fAi iE MAM`cSe.aldMUCC:`0El.ii'NG PLKe ROW'` AREAS i,•
0.NL'Y, 7748111.79/177C3tbt,.'LP M6llrV11AN
IVALUATION 7,511%.100 Ls'
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..jt S' ':t'fVB A A"tee) iST. (3, Cf) ,'a"Ri7":"II': ON
yy. yy qq . 7j ! y '`, ., $ (j { ,y
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90A. .K 1!1.inS300)
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` • , 4TAL CONSMUCTION ANYy.t PIAN CHECK
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LESS .'1 t.fx-I-IAL.7 i'b'S.: i
X1997
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PR.6,iRx.l'ti" FERS 011E MEOW
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RECEIPT n
DATEs
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
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
BLOCKWALLA60ROVALS
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
s
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)