PLBG (0004-133)'LICENSED CONTRACTOR bECLAR'ATION,'
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with S6cti6n 7000) of Division 3 of the Business and
Professionals Code, and my Licens6'is in full force and effect.
Licbns6 # Lic. Class Exp, Date
746159 '42 02/29/2(
eignature of Contractor
y
• 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 offered for
sale (Sec: 70441" Business,& Prof essionals *Code)-.
( ) -, 1, as owner of the property, ,am exclusively contracting with licensed
contractors to construct the project (Sec.,7044, Business & Professionalsi
Code).
I am exempt Under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pen'alty of pe'rjury one of the following declarations":
I have and will maintain a certificate of consent to self -insure foi workers'
compe nsation, as provided for by Se * ction 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—,
MUM FKAOLE MS.-,
(This section need not be completed if the permit valuation is for $100.00 or less).
I certify that in the perforrfianceof the work for 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,°ana agree that if I should become
subject to the workers' 6ompensation.provisions'of Section 3700 of the Labor
Code, I shall forthwith comply With th-016–provisions..
Date/ 0 A � Applicant 7_
�5
" –,,
Warning: Failure to secure Workers Compe io_t.–
n 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. .11 , -1, "i- I - � i ~ I .
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 applicat6n 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 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.day ' s 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-mentioned propertyfor inspection purposes.
Signature (Owner/Ageint)_/ >),,�' Date
V
PERMIT#
)-oio BUILDING
DAT,PERMIT
DATE VALUATION LOT 0004-133 TRACT
JOB SITE
APN
ADDRESS 524W AVFXWA KAVARRO
773-275-..0 . 7
OWNER
CONTRACTOR/DESIGNER/ENGINEER
13RAY, MS ROSnGk=
EC090 SEVMR SERVICE
52 -400 AVEMA NAVARRO
8403.5 CABA704 RD; MDIO, CA,.92201
LA QUWfA CA _02253
PAIM DESMT CA 922 41
-
(760)346.2793
USE OF PERMIT
PLUNMIgG
SEPTIC ABANDON - SEWER CONNECTION • LOW -MOD PROJECT -4
CONT kACT MOUNT .1,025.00 LS
L=W, ATED CdFf OF CONSMUMON
.1,625.00
PERMrr M SUMMARY
PLUMDING FEE S 101-00"..19-000 $30,00
SUB -TOTAL CONMUCT1014 ARD PLAN CRECK
$30.00
LESS PRF,-PAIDIMES
$0.00
TOTAL PMWf MS DUR NOW
$30.00
RECEIPT
DATE BY
I ,
DATE FINALED
INSPECTOR
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
- 5 - o o
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final (o pp
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)