RR (9701-094)78989 Calle Mazatlan
9701-094
LICENSED CONTRACTOR DECLARATION 1'
I hereby affirm under penalty of l5erjur*
y*that I am licensed under 'provisions of
Chapter 9 -(commencing with Section,7WO),of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.,
License#
$711 Lic. Class Exp. Date.
D
3 1197
Date Signaturel6f'Contractor
-OWNER-BUILDER DECLARATION
I hereby affirm under penalty of, perjury that l'arn exempt from the.Contracib"r's
Licehse Law. foi the following reason:
on:
1, as owner of the propqrty; or my employees with. wages as their
- hr sole
compensation, will do the work, and the structure is nountencled or offered for
sale (Sec. 7044, business & Professionals Code):
1, as owner of the pr6peirty,.,arn 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
I hereby. affirm under penalty oi'perjury one of. the following d6claratiofis
O 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 3760 of the Labor. Code: for the pqqormahce,o.f the, work.'for.which this
permit is issued. My' Workers' compensation insurance carrier & policy, no. are:
Carrier Polic , No. :' . 1 1. , .,, 1:
.- . -': -0407624.96
IfATE FUND
(This section need not be completed if the. permit valuation. is for $10.6.60 . or less).
(_:certify that in the performanceofthe work for which this permit is issued,
I shall employ any person in any manner so as to become subject ta.th,6
workers' compensation laws of California, and'agree that if I should bebome
subject to the workers' compensation provisions of.Sectio rY3700 of the.Labdr
Code, I shall forthwith comply wit S'67 O&SIO
Date: Applicant !/
Warning: Failure to secure Workers' C6rnpensation coverage is unlawful and
shall subject an,employer to criminal penalties and civil fines upto$1100',0001 in
addition to the cost of compensation, damages:as provided for in' Section 3706
of the Labor'Cocle, 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 mdde"&each 'per'so'n.at
whose request and for whose; benefit 'work is performed under or pursuanuo
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-.
2. Any permit issued as a result of this application bec6rnes null -and void if
work is not comVienced, within.`, 180 days from date 6(is suan& of'such
permit, or cessation of work for- 180 days will subject . permit rmit to cancel.latiom
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 ctiuthoriie repre.s6ntati . ves of this City to enter, uobn
th6above-mentioned'propertyforiiisp'ctionpurooses
ly
Signature (Owner/Agent) .6ate. 7
BUILDING PERMIT
PERMIT# r CONTROL#
970J.094
041.
DATE4
.4)() LOT
14/9VALUATION 1
7 53I'MA
TRACT
JOB SITE
ADDRESS 8-9491 91 AZATU% A.
7.9CAJAA,31,
.1
APN
OWNER
CONTRACTOR DESIGNER / ENGINEER
A'
N%T&TUM PACIFIC R-10fRNG
Po Box, 12116
34P, LA CAMPAiKA WAY
TA QUIM.1A. - C!A.
PALM SPRINGI.; 9T2,60
C' A.
CALP,
42ri3
USE OF PERMIT
'801LMNO
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300,00 LS
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JP,_VYr_1kf1 Cowjrft M, OWANORIAWQi-TMCK
SAID .00.
LESS M-PAIDERES
TOTAI.:P ERMIr.f. FX ES :01i9 NOW.
.7
RECEIPT
..J.
DATE
BY
1
DATE FIN ALED-
INSPECTOR
PECTOR
111W1111111
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
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
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:
,tom
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)