0012-050 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under of that I am licensed under of
PERMIT#
BUILDING PERMIT
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penalty perjury provisions
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Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals
DATE VALUATION LOT 0012 -OW TRACT
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Code, and my License is in full force and effect.
1218M $757.75
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License # Lic. Class Exp. Date
JOB SIDE
ADDRESS 5245A5 a�.Y'F.1 IDA 1H +�'.�i;).;T AS
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CONTRACTOR / DESIGNER / ENGINEER
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Date t �' Signature of Contractor
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OWNER -BUILDER DECLARATION
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PACIPIC'�'}��;�ES CON;��;[�'��'C;T`,(�; .
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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1719 P, 5MMONT
License Law for the following reason:
CCEA*n. ME CA 92,051
.4 OCEMISIDE CA 92054
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( ) I, as owner of the property, or my employees with wages as their sole
(760)9-6-7-0069 MIA, 1935
compensation, will do the work, and the structure is not intended or offered for
USE OF PERMIT
sale (Sec. 7044, Business & Professionals Code).
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( ) I, as owner of the property, am exclusively contracting with licensed
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contractors to construct the project (Sec. 7044, Business & Professionals
GENERALiit3ILDING
Code).
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() I am exempt under Section B&P.C. for this reason
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Date Signature of Owner
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0IDN WALLAND PROPAWE EWCILOS J&Fi ( '1'Y'S'1'.14NDA�,�tD)
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
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( ) I have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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( I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are:
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STATE FUND t2' G�i?t+
1�`f,�UTED COST OF .N'b:C�lE7CT ION
757.75-
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PERWR FM SUMMARY
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(This section need not be completed if the permit valuation is for $100.00 or less).
CONS RUCTIUN FRE 1 f71 -000-4 18-000 $21.00
() 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 the
workers' compensation laws ofNCalifornia, and agree that if I should become
%subject to the workers' compensationtorovisions of Section -3.700 of the Labor
3
Code,Ihllo hyu comply wi;h)hose prgvisions.
Date: (( Applicant ��.•1i VV� r
Warning: Failure to secure Workers' Co pensation 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 person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
SUB-145TAL CON•:3`IRT-`t::`1104 fiXID PLAW CIIROIC.
$21,00
any.permit issued as a result of this applicaton agrees to, & shall, indemnify
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& 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
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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 rauthorize representatives of this City to enter upon
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t the above-mentioned prope"rty f r inspection purposes.
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Signature
RECEIPT
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BY„)
DATE NA
INSPECTOR
(Owner/Agent) , M----� Date
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 Hacks/
Electric Bond
Footings`
Main Drain
Bond Beam
_
Approval to Cover
Equipment Location
Underground Electric
Final
A
5 4z n /
Underground Plbg. Test
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:
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.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)