0303-063 (BLCK)- LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 UJ Professionals Code, and my License is in full force and effect. tel
C) License # Lic. Class Exp. a�teJl
LLJ
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i
Z �l Signature of Contra for 1 �
(p O. i
J U � OWNER -BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason:
Z_ ( ) 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co O I am exempt under Section , B&P.C. for this reason
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N Date Signature. of Owner
O �
EL Z WORKER'S COMPENSATION DECLARATION
It CD I hereby affirm under penalty of perjury one of the following declarations:
U) O () 1 have and will maintain a certificate of consent to self -insure for workers'
XW � compensation, as provided for by Section 3700 of the Labor Code, for the
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Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers' compensation insurance, as required by
' O U QSection 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
'IT CIS z Carrier xrj6N,� � NJUN F.' Policy No. 70M09
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(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 person in any manner so as to become subject to the
workers' compensation laws of California, and agree, that jif II should become
subject to thea workers' compensation prov`sions of • ection,37 0 of the Labor
3 Coded �hallFjQp,�rthwith cpopmpJy ith t tose�roPvisions' ; t
Date: i V% A Ii a t"? �'� -�- a f
Warning: Failure to 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
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
& 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 a)I-City,Aand State laws relating to the building
construction, and hereby authoize representat'ves of this City to enter upon
,tfie abo�ue "mentioned p� perty for Insp°ction purp0 es. f
Si na' ture Owner/A n�� - ,�� r
g� (y g ) Date
BUILDING PERMIT
PERMIT#
%
DATE VALUATION LOT
0303-00 TRACT
��yy ����1r yy//�� p fly ��
0.31%�iSm - ll.�Yf o7�7 FfG/
y 7 �y
t L X18
F.
JOB SITE
ADDRESS oiml JJM' TL1iiMt1M3.i.eA
APN
OWNER
NTRACTOR / DESIGNER /EIV INEER
61-260 AVENUE 62
81 >260 AVEM1 62
TIM IRMAL CA, 928V
`PIR:�:'�MAL
Cts 92883
(909)833.6999)
CBUI 606
USE OF PERMIT
GS9Y :tfALBixUMING
70 LY of 61 OA.PD7,14 WALL: CIRCO ST,M)ARD
6 F'T. WAIT IW
70,00 LF
EMMAIM COST 010 CONYMM°`i',dON
9,?��ft�fltl
M. WT ME IRUMMIRY
CONSTRUCTION FEE 10),-000-41"00
$41,00
C (MEM 'kldM
LF23 PRE
$48.00
$0.00
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CIT'f of i.
FlNi. CE QED';.
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RECEIPT
DATE
BY r
FI E
IN
OR
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
Electric Bond
Footings
Main Drain
Bond Beam r
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
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:
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