Loading...
9806-009 (SFD)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 Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date.-; ,s55(i5 13 t'if3Giv9 Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury'that I am exempt from the Contractor's License Law for the following reason: 44 ( ) I, as owner of the property, or my employees with wages asjtheir 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 pr6perty, am exclusively contracting with, licensed contractorslto construct 'ke project (Sec. 7044, Business &,Professionals Code). () I am exempt under'Sectlon B&P.C. for this reason Date ` ..Signature of Owner WORKER'S COMPENSATION DECLARATION 1 I hereby affirm under p�egalty 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. ( ) I have and will nrpintain workers' compensation insurance, as required by Section 3700 of the LabortCode, for the performance of the work for which this permit is issued. My workers'. compensation insurance carrier-& policy no. are: Carrier Policy No. ate, A t'i:�m 7 G!i ,fit ..9T,� i i4r'. 1' i.�ii u� (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 if I should become subject to the workers'. compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: ADolicant 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. p 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 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 inspection purposes. Signature (Owner/Agent) Date BUILDING PERMIT PERMIT# 980&4J09 'S +R •'1'1 .DATE VALUATION LOT TRACT .1 MOM $120.486.:30 11,12 JOB SITE ADDRESS 53 -UO A NWANrinSCO rPN 1 OWNER CONTRACTOR/DESIGNER/ENGINEER MHN P DYCK u rlAl:ri L SIVA; /'E 7494 SHASTA HORES"', UIR PO .BOX 51161 I,..A f,?L.1iwm CA 92253 -S-13"1r1GT.,ery..)WN CA 96088 CAN'1'O1+1 %AKF C.'A, 92587 .. (760)7'1-5452 GIBL9 1794 USE OF PERMIT S1hIGf�F i~.A11'�Il,,'I` ,��A7-l.t,l.,EAicy ' Slip - 3�"CR1uE ` 130)rS bi0'l' INCLU_X BLOCKWALLS OR FOOL L> ` RUIC`1' CONSTRUCTION 1,977.>riD SF K)RCH1PA'T10 64.00 3F UARA.t;.Oc AKPQRT 540.00 8-F 6 FT. WOOD:lP9fq 'Ji 200.00 LF ES T IMXfE P COS OF 6.11`+'5I I$�C"I «s31di 120,486.30 s';CJNST'RUCTIC)NFEE 10.1•-000will.84)0U 713:titti Til:, AN (11K ;1` le i?; 1011-f- .-a1.,3ID- t 111 $613.4? ,NU3 ;UM4iCAL F=FX 101-000-42,11-000 371.71,00 E L EC, €"111CAL LE $190.1130 PLUM6'1NO FLZEs S`7!'RON(I Mot 1t 0'N FM - gh-M) W-000-244-000 -000 $1.Z 5 flflf?.32AS1R6CT'UT,W, FEE -12 5-0�.W-443-342 $216331A ID(Rk D;1'[3.i3:LrYIV -101-0W-441-.345 E UE RPOS1.T 101-000-43'1)-315 4250M SI.113-TMALI I CONFYRU(MON AND PLAN CHECK $4,502,73 - LESS+ RU -PAID VERS 4250.00 - TOTM, PERM.IN F LEN DU NOW RECEIPT DATE BY DATE FINALED INSPECTOR I% INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings YX -ksW 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 A PROVALS steel Set Backs Electric Bond Footings 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) 07 ELECTRICAL APPROVAL Temp. Power Pole t 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) s