BLDG (0009-160)LICENSED CONTRACTOR DECLARATION
I hereby affirm -under
u , rider penalty of perjury that I 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.
Lice'nse #
_Lici'Class Exp. Date
43 1
07131
/Date Signature of Contractor
OWNER -BUILDER' DECLARATION
I hereby affirm' under penalty of perjury tliat I am exempt from the Contractor's
License Law for the following reason:
1, as owner of the property, or,my.employb'es with wages as their sole
compensation, will do the work, and the'structUre i'§'!hot 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 & Professionals
Code).
I am exempt under Section B&P.C. for this reason
Date Sighature 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
p4Fmit is'issued. My workers' compensation •insurance carrier & policy no. are:
Carrier STATE FUND
Policy No:
(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 persorylinany manner so as to become subject to the
workers' Compensation laws of California, and agree that if (,should become
subject.to the,workers' compensation , provisions of Section 3700 of the Labor
Code', hall,f6rthWith comply witff those provisions,,,,
-Date: Applicant
Warning: Failure to secure Workers Compensation coverage is unlawful and
/Wa I C
shall subject an employer to criminal p6nAie's 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 pursuant to
any permit issued as a result of 'this applicaton agrees to, & shall, indemnify
I & 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
the above-mbntioned property-,for'inspection purposes.
Signature (Own'er/Agent) Date 9.
V
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS07A.
53-�465 AVEMDA W"
OWNER 'INFER
CONTRACTOR/DESIGNER/EN EN6
PACIFIC IRPMM CONSTRUCUOR PACT FIC: TRMn CONMUC1109
1719 a -pluam.. 1.719 SMEMONT
S OCIEANRLDE CA 92054 S OCE-AXWE CA 92054
(760)96? -006.9 CBII# 1955
USE OF PERMIT
GEW MAL BUILDWO
73 LIF X 6'R WCK'WALL (ORCO SYSTEM)
6 FIL WALI.,
EMMAIED CULT Or, COWITZMMOn
PLRMM FER $MMUARY
CONSTRUCTION FEE 101 -000-43 &000 443.0
STJBIATM CONSTRUCIT014 AMOPLAN CIMCK
LEM PRF-PAU) FFYS
T47YALM1lUT MS DUE NOW
RECEIPT DATE001 BYI,\f
9 DATE FINALED INSPECTOR
9
3.00
$0.00
i
1*'w 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 APPROVALS
POOLS - SPAS
Steel
Set Backs
Fie 6N0 S
Electric Bond
Footings
Main Drain
Bond Beam
Q - - DD S %
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
991
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: