BLDG (9607-083)77233 Calle Mazatlan
9607-083
LICENSED CONTRACTOR DECLARATION;
I hereby affirm under penalty of perjury: that I arri 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 # r Lic. Class Exp. Date
Date 9 Signature of Contractor 2',Z -
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).
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 Owner
WORKER'S COMPENSATION DECLARATION"
I hereby affirm under penalty of perjury one of.the followingtdeclaratiohs:
() 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.
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. Wy workers' compensation: insurancecarrier & policy no., are-.
Cartier -Policy No. ,
(This section need not be completed if the permit valuation is for $100.00,6r. less).
( ) I certify that in the performance of the work for which this permit iissued,
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
subject to the workers' compensation provisions of Section 3700 of,fhe: Labor
Code, forthwith os
I shall fortcomply with the provisions:-
Date:1'2- tg Applicant ' y,. es/G%` !ir/ •'
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 3.706
of the Labor Code, interest and attorney's -fees. " , C
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. i
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
any permit issued as a result of this applicaton agrees to, & shall,'indemni
& hold harmless the City of La Quinta, its officers, agents and employee . D
2. Any permit issued as'a result of•this application becomes-null•and void _
work is" not commenced within 180 days from date -of issuance ,of suc
permit, or cessation of work for 180 days will subject permit to cancellatiql
I certify that I have read this'application and state that the above information
correct. I agree to comply with all City, and State laws relating•to the bulldlh6 p
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property ffor Inspection purpo es
Signature (Owner/Agent;l- _, •_' Date 7
" PERMIT# . CONTROCN ,
BUILDING PERMIT - 9Jrl la .a9t, 3755'
DATE VALUATION LOT; TRACT "
JOB SITE
APN
ADDRESS7' 3SCA1 9.,.BSi >i'fi,/ e :7 .ii✓AN (Ai5`E i
OWNER - ',
CONTRACTOR/DESIGNER/ENGINEER
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'GA. QUINT A rte 9.2.254
11,AIGIM S#'bt.INGS • - i"..t\ 92760
USE OF PERMIT
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, U L 2' 3 1990 _ - " a 9:i , .L . S= 3 l3a WCi iY
$3100
RECEIPT
DATE"
BY;':
DATE FINALED
INSPECTOR
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
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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
COMMENTS: ,
/0*41
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)