BLDG (9705-126)77333 Calle Mazatlan
9705-126
110ENSED.CONTRACTOR DECLARATION
I hereby affirm under penalty of perj . Ury'that I ani 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
C%Aq %r
2`157 1
IDate "Signature of Contract
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of.perjury 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-offeredfor
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively. contracting -with licensed
contractors to construct the project roj6ct (Sec. 7044, Business & Professionals
Code).
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 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
( 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.
(This section need not be completed if the permit valuation.is for $100.00 or l6S4
*( .) I certify that in the performance of the work f6r 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, and agree that if I should become
subject to the workers' compensation
prov onsof
Section ,3700_
of the Labor
Code, Ishall forhwilh comply with thoseptovisions.
Date:
Applicant—'
Warning: Failure to secure Workers' Compensation coverage -is unlawful and
shall subject an employer to criminal penalties and civil -fines up'to I $100,000, -in
addition to the cost of compensation, damages as provided fo.r.in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is her . eby,made to the Director of Building and Safety
.for a permit subject to the, condition's and restrictions set forth on ..hi's
application.
.1. Each person upon whose behalf this application is made & each person,at
whose request and for whose benefit work is performedunder or-pursuant.to
any permit issued as a result of this applicaton agrees to, &.shall, • indernify
& hold harmless the City. of La Quinta its officers, agents and employeg§.
2. Any permit issued as a result.of this application becomes null and *void iif
work is not ,commenced within 180 -clays' from date of,issuancd-of SUA
permit', or cessation of work for 180 days will Subject permit to cancellation.
I cIfy that I have read this application and state that the above information is
coyect. . I agree to comply With,all City, 'and State laws relating to the building
cpnst uction and hereby authoirize, representatives of this City to enter.uppn .
2
e above-mentioned property forlp9pection purposes
Si nature 'Owner/Anehtl Date
M
PERMIT # CONTROL#
BUILDING PERMIT 9705426, 5213
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 17-333 Q iLLE4 PWAZATLAN.
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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USE OF PERMIT
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RECEIPTDATE
BY
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JINSPECTOR
7
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 P OVALS
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: