Loading...
9907-520 (DSF)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professi ' onals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 6 C9 Ci 3 llr",19! r _Z_�O Signature of Contractor a /te -47 9 �' 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. 7044, Bdsiness & Professionals Code). 1, as owner of the prop&tyl am exclusively contracting with licensed contractors to construct the pi�oject (Sec. 7044, Business & Professionals Code). I am exempt under Section B&P.C. for this reason Date Signature of Owner WORKEWS COMPENSATION DECLARATION I hereby, affirm -unqer 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. (Nf 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 c7arrier & policy no. are; Carrier Policy No. 117 NUN 1) le 19 (This section need not be completed if the permit valuation is for $100.00 or lets). I certify that in the performance of the work for which this permit is issued, I shall not4mploy any person in any manner so as to become subject to the workers' compensation laws of Calif orn. ia, and ag.ree that. if I should become s u Z ,Pject to the workers' compensation provisions of Section 3700 -of the Labor ode, I shall fo%with comoly'with,those,provisions Applicant— 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 app!icaton 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 bec6mes null and void if w6rk 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,l have read this application and state that the above information is 11 correct. 110agree to comply with all City, and State laws relating to the building const ction, and hereby authorize representatives of this City to enter upon th /above-mentioned property for inspection pu(poses. Signaiure (Owner/Agent) Dat/_�17A BUILDING PERMIT PERMIT# 2 "07-15AM DATE VALUATION COT TRACT JOB SITE ADDRESS 7&"0 AVENIDAFERNAN DO 631-734-060 OWNER CONTRACTOR / DESIGNER / ENGINEER 76MAVENIDAFEARANDO 77.453 BRUS1iV11(X)D.D%& LA QUINTA CA. 92253 PALM DESERT CA 92260 (7160779- 131916 USE OF PERMIT WRIZOVAL OF RM3 DAWIC M.D.RY_Ar,,dJ,.& funutialoK iisu..,vcsop 00MLONG PERA41T. "VALUNVION 0300,00 LS COST OF CON= R."ITT.1111011\1 4.340.911) AYCAMITFUT, SUMMARY ]DI-13010LI If 1,0144 YER U 5. IN) CONSTRUK-7;IONAND AAWMI"N, 54%. M, USS PUTAID�TXS $0.00 'YOTIM., PERMIT FF11 Ins- DUK, NOW $41.00 RECEIPT DATE FINALED INSPECTOR INSPECTION RECORD OPERATION I DATE I INSPECTOR OPERATION I DATE _—TINSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck ExhaustFans OX to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Partv 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 Approval to Cover Equipment Location Underground Electric Underground PIbg, Test Final Gas Piping —PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure ShowerPans 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 -7Z?Al �Kf 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: