0212-005 (RER)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
f— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
W Professionals Code; and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
I LU
Z t-- d'Dat, / Signature of Contrac o/ �
(ZOO'0 a"!
J OWNER -BUILDER DECLARATION
W WI hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) 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).
c� ( ) I am exempt under Section B&P.C. for this reason
u')
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
CL
o< CC I hereby affirm under penalty of perjury one of the following declarations:
U-)
� O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
O _J _J performance of the work for which this permit is issued.
M Q () �(./) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Zpermit is issued. My workers' compensation insurance carrier & policy no. are:.
oo 0 Carrier ,`"'..ATS FUND 2"02007.066
No. 2"02007.0n6
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J (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 sw` s to become subject to the
workers' compensation laws of California,P Rd agree that/if I should become
3 subject to the workers' compensation�0�sions-of Section 3700 of the Labor
Code sh lbf0rt�with comply with those provisio s%' 1
,,✓Date• 1 7!.
" 1Applican � .'f f,/
r
Warning: Failure to secure WorkeC' Compensation/verage is unlawful and
shall subject an employer to criminal penalties angiclvil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in SecLe
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building afor a permit subject to the conditions and restrictions set fortapplication.
1. Each person upon whose behalf this application is made & each whose request and for whose benefit work is performed under or puCIany permit issued as a result of this applicaton agrees to, & shall, i
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit; or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for ins6ctiti'oon purposes.
,.I, Signature (Owner/Agenil � �'�/l'1.!� /. �--._� Dale✓
BUILDING PERMIT PERMIT#
DATE VALUATION'y LOT tf,6AZ ✓'. k TRACT
JOB SITE
ADDRESS 79^{3
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
HOYT CWTWOOD
M]ttaSOW D_V1V7 �.,LbTfA°C
179-900 (=U'S
44 -3 06 MUS QC'� IR DR
TAQum A CA 92253
xeMi. NIVIFUIS C11% 9'2.210
(760)773-4487 MVV 664.5
USE OF PERMIT
( E29 AL BU,FTONG
.t DT)ITION OF FiREP€,.A.CF TO A A,".TM BEDROOM OV MZ'S'! IM0 5;'.17 c?9;.P,.
APPROVED .P'LI}3+15 HOA,A.PPAGIVAL, 03N MIX&
VALU a IOC cl .sly TA
-FMIX&T D 0091, OF s ON-TrRUCITON
CI,)
PURIVVITEM 6TWAIA Y
PL1W uHWK FEE ? �1a000-439-318 SDI$
CO1gSTRUC'TIC;H FZF, I I.0 0-Yi i a-000 $21.00
,.rRowo manmt rsr-1~m1b 10'1000441-000 S.30
s
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T.
If 0 QUIN'TA
INANE DEPT -e 34 C}Tf COM�YTt"�'tORAW? aC.ia+Nr Ci ('L
1: 5.15
LESS
LESS PRE -PAM AMS
YOXA.T, S'3MU11 V EMS MA -1 NCS
RECEIPT
DATE
1, -�-cd
BY
1 101-. T1
DATE FINALED
-3
INSPECTO
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
2 — — Z
Final
Final —
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
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 Vottage 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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