BLDG (0002-144)i:., .. .!
LICENSED CONTRACTOR DECLARATION
by affirm under penalty of,perj6ry,fhit I am licensed under provisions of
hapterb9 (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 .
493499 B C3
.pate %` >�Signature of ContractIn
OWNER -BUILDER DE&ARATION
I hereby affirm urider 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)?
( y^) I, as owner of the property, am exclusively contracting with licensed
----contractors to construct the project (Seca 7044, Business & Professionals
Code). a
(') I am exempt under,Section B&P.C. for this reason 4.1
Date Signature of. Owner
WORKER'S COMPENSATION DECLARATION 3, .
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'
comperisation, as provided for; by Section. 3700 of the Labor Code, for the.
performance of the work,for which this permit is issued.
( j 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 carrierY & policy no. are:
Carrier Policy No.
WC3-1 19-059S
(This section need not be completed if the, permit'valuation is for $100.00'or less).
O I certify that- in the performance of the work for which this permit is issued,
I shall not employ any person in any manner sous to become subject to the
workers' compensation laws of .California, and agree that if I should become
subject to the workers' compensation provisions'of Sectio .3700 of the Labor
Q6e, ll, shall rfortthw,3iith-somply4w,ith.tkgse,provi9ions.^
1�ate: ,Applican7 U-:..
Warning: Failure to secure WorkersCompensation 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
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 persori 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
& hold harmless the City of La Qulnta, 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 authorizerepresentativeg of this City to enter upon -
the/above-mentioned property o_ r inspection purpo`es
gnature (Owner/A�/ 6atle
' BUILDING PERMIT PERMIT#
yy
•
DATE �I VALUATION Iz.� I:A.:1I� LOT TRACT
JOB SITE
ADDRESS 54.035 AVE. ME1VDOZA
APN
h
OWNER _-
CONTRACTOR/ DESIGNER /.ENGINEER _ _
rte,Lrn]s�•'�[ e(rrc.r rr
,J, vi �'.L:1%dl'Y �Y.L lI,�...1
rr �'ta r.r tet• ti�u-�r i qY(y ((z f „ •n ti trMr) r'
e. Jlti\.l'. i.: ♦..1 � l"\l .A.Y'y%'�V\-•1. 1\.JS.V
P.O. BOX 1004
P.O. BOX 024
�L{ICJ MIRAGE 'CA 92270
R A:C,:M 0FES ?RT CA 9,261
('ll,•dj568t 4963 CT3 X 7�215
USE OF PERMIT
Si)kiE4TAL 'TO 9405-1,16i%.F.''X Y(r) CAtD3N WALL CU Y g
S'
eTfANDApDCER APRO 'E 'LANS ONLY
1 �
i
5 FT. WALL 70.00 LF
k
ENTMATF91""61 ca�T OF CONSTRUCTION
PERi U 6. FS I': S•!JM.M AR
C0NSrKL[(-,rf0N HE 101-000-448-00d S.117,00
"UR 'tKYTAL OiY?tiiS7T CJ "I'ttYN Ain MA;v c Nla^O,L
$37,00
i, .r � "iiJ�li"�,•�iJ. t'
$0.0v
11'arAlI.;€^ i'll""IT F.C11's gayt,•>NOW,
S37.00
i s
RECEIPT
DATE
BY; �`�;it�)
DATE FINALED
INSPECTOR
I
��
rte•
I
IV0 : 9
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
Exterioi Lath A
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs I s -7
Footings z
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final oi�
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: