0011-178 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under pr'ovisions.of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect. .
License #, Lic. Class Exp. Date
� 5!f l � ' `�.' i tom• 0�/Z
Date �'� Signature of Contractor
OWNER -BUILDER DECLARA ION,
I hereby affirm under penalty of perjurythat I am exempt from.the Contractor's
License Law for the following reason:
( ) l,. 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. 04 Business & Professionals
Code).
O I am ext mpt under Section ' B&P.C•or this reason -+
Date i - Signature of ,Owner f,
WORKER'S COMPENSATION DECLARATION
I' hereby affirm under 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, fo;, the
performance of the work for which this permit is issued. '
O 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. -
STATRYi3 D 12831 9`.•Gfi :.
(This section need not be completed if the permit valuation is for'$100.00 or less):
O I certify that in the performance of the'work for which this permit,is issued,
I shall not employ any person 'iri\any, manner so as" to become subject to the
workers' compensation laws, of CaVornia„•and agree that if I should become
subject'to the workers' compensation prolisionsCof. Section 3700 of the Labor
Code, I sh` II forthwith comply with tho a provisions �.
Date: ( ?'i Applicant
t.
Warning: Failure to secure Workers' Comp nsation coverage is unlawful and
shall subject an employer to criminal penaltie 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 isnot 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 autoriz �rePresentatives�of,this City to' enter upon
the above-mentioned property for in ectlon purposes. •' O {
Signature (Owner/Agent)C�rS. p to
BUILDING PERMIT PERMIT#
DATE VALUATION LOT?Y"� + TRACT
IMAM= $4,71AS
JOB SITE
APN
ADDRESS � C.35 ,t ggyyYM••pppp pp Vaayy R
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
171 p 3 TIGWON't
1719 0 TWRTWONT
S OMdt,? MME CA 9204
0. OCEARITI13N.'Y CA4�
9205
�
1)�%V � -006 �tt� ��J
«a•.:..
USE OF PERMIT
(ILKI ddAL BiMM9
100LYXX;UIT 01111*t'Cf'b17ALL. OPWO SYSTEM
20 LY X 4' 1;ROPAWE f?4+1CLOSUR.E 7 I �t 5` O:Ai DEN WALL,
$ f. 'W ALL 7,00 LIP
4 VL 'fii'ALL 10.60 LF
p 7 n. IgUMM. ARY
P
CCaAi mtBctlem1ist 101 -0 00-418-000 00 S15A
T
gd1-TC"51!,.AI, C;t1MMUC1'fttX./1.%17L? PLAN' CINCK.
]XISS PRE -PAM :CRI y
$0,00
RECEIPT DATE��r� BYy DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE I
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 _/
Footings (� —� 5
Electric Bond
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
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)