RR (9701-094)78991 Calle Mazatlan
9701-094
LICENSED CONTRACTOR DECLARATION
'I hereby affirm under penalty of perjury z that I am licensed under provisions of
Chapter 9 (commencing with Section 1000) of Division 3 of the Business and
.Professionals- Code, and my License Is in full force and effect.
License # Lib. Class Exp. Date
235717 C.N U311,97
Date Sigor
nature Of dontract
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that f am exempt from the Contracibes
License Law for the following reason:
( ) 1 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
,sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property,.am exclusively Contracting With licensed
contractors to construct :the. project (Sec. 7044, Business A Professionals
Code).
C0 O I am exempt under Section B&P.C. for this reason
NDate Signature of Owner
0
0 -CL WORKER'S COMPENSATION DECLARATION
. .
M.Z I hereby affirm under' penalty of perjury one of the following deplarationb:
U) cc ( ) I have and will maintain 0 certificate of consent to self -insure for workers'
X. W L—L compensation, as provided for by Section 3700, of the Labor Code, for the
0 performance of the work for which this permit Is Issued.
I have and Will maintain workers' compensation insurance, as required by
0 Section 3700 of the Labor. Code; for the performance of the, work for Which this
cy) permit Is issued. My Workers' compensation insurance carrier & policy. no. are:
Z Policy No.
-00 S'fATUFM 04S76247-94
(This section need not be completed N 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 -ft
Workers' compensation laws of California,. and agree that. if I should bet
subject to the workers' rkers' compensation provisions of Sqctioy3700 of the Labor
Code, I shall forthoith comply with
Date: L It 11 Applicant_
Warning. Failureto 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
fn of the Labor Code, interest and attorney's fees.
IMPORTANT Application is'heieby made to the Director of Building and Safety
for'7 a permit subject. to, the' conditions, and restrictions set forth ion' his
appllcatlon.
it
66h person upon whose behalf this application is maide'& each person at
:3, whose request and.for whose berief Work. is performed brider or pursuant'to
s -. any permit issued as'a result of this appilicaton agrees to, & Shall; Indemnity
J 4 hold harmless the'City of,La Quinta,. its.-officers;1agents,and employees .
57; 4 IC -
Varid'vold if
-application becomes, nui''
2.'Any permit issued ad'i result of this
commenced within!, 180 days from date 6f.ldsuan of'such,",
'work'ls not a a ,Issuance
3
,i.p6rnit-'drc'esiation-.of work for -180 days will i6bject-oirmit to caricellaboh:.*
.. ';, 'A
application and state
X 1, certify that I have read th, ii that tfiIi above information Is
- ,fdjree to comply refatirib-6,"'buildirid
C6 stnktid And beriby,.Aiiih&ii
6-, rb6ri.s9nteiv 9 &: thli 6" to6htej, doop
OT"ni
PERmrT # CONTROL#
BUILDING PER1MIT-'- ,,!. ;,,.i.:,,,. 1,9701-094' 464V
. I .
DATE VALUATION LOT'. };3 TRACT
1124M7
JOB SITE
ADDRESS 7&91A9t991C-ALLXM MAZATtAPN
A
J
OWNER
CONTRACTOR DESIGNER / ENGINEER
SANTA R.OSA COVE 110A,'
11hrESMRN PACIFIC R.00FtNG
K) BOX 12"no
302 LA CAMPANA WAY
LA QLJI:Nl',A. CA
PALM SPRINGS CA 92260'
(619)32o-Eo22 CHLO 4 lvs
4,
USE OF PERMIT
JU4COOP'CRA DUPLEX
X
01,
FUSTI MATED COSI OT! CONSTRUCTION'.
PERMIT FIKESUMMAKY
RFA0017 Ffffi 1014W4184M $3000
%
tib
,
M 41
C:z
}$30.00
sug-Ta rAix'ONSTRUC'"noN ',AND PLAXCH.em
Y Y4 -PAID FE
LW PRE ES
.
V
TOTAL. PERMW FIKES DUE NOW,
%
A1,116
ti dr
$
RECEIM . 1,
MKT
DATE FINALED, ,, 4.
INSPECTOR
F
INSPECTION RECORD
_OPERATION - ' -
F - DATE
J'INSPECTOR
OPERATION
7T_F_
DATE
INSPECTOR
BUILDING. APPROVALS
MECHANICAL APPROVALS
.set Backs
Underground Ducts
Fame & Footings
Ducts
,Slab Grade
Return Air
Steel
Combustion Air
Roof Dock
Exhaust Fans
OX to Wrap
FA.U.
Framft
Compressor
Insulation
Vents
Fireplace P.L -
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Unes
Party Wall Firema -
.*1E)dvior Lath
• Ederior
Drywd - Int. Lath
Final
.Rnd
POOLS - SPAS
BLOCKWALL APPROVALS -
steel
Set Backe
Electric Bond
Rwomw
Main Drain
Bond Bearn
Approval to Cover
Equipment Location
Underground Electric
U"round Plbg. Test
Find
Gm Piping
PLUMBING APPROVALS
Gas Test•
Electric Final
Waste Lines
Heater Final
Water P"y
Plumbing Final
PkmftV Top Out
Equipment ErrJosure
Shower Pan r
OX for Finish Plaster
Bawer Lateral
Pool Cover
Sewer COrWWKMM
Encapsulafion
008 P"
Gas Ted
Applianca
Final
COMMENTS:
`
/
Find
Utility Naim (Gas)
ELECTRICAL APPROVALS
TOM. Power POW
urwWwound conduit
'RoughWftq
LowVobgeWhV
Fbdurw
Main Service
Sub Panels
EAw1or Receptacles -
G.F.I.
Snuice Detectors
Temp. Use of Power
Notice (Perm)
I