9711-049 (BLDG)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'.p e
License # Lic. Class ate, -
" 42 j3 2i?ti/:i
�2Date ignature of Contracor j
OWNER -BUIL EECLARA ON
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
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, for the
performance of the work for which this permit is issued.
( ) 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
()0, 1 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 Calif or I ,,and agree that` if I should become
subject to the workers' compensationa�ovisi S of Sectr 3700 of the Labor
Cod I a� fo �i f�` omply with' Be pr visidns.
/Dat Applicant
i
War ing: 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 all City, and State laws relating to the building
construction, and hereby authorize r�tatiues of this City to enter upon
the above-mentioned property foyin?;pectioP purp0 es.
i .r
I/Signature (Owner/Agent) �� Date
BUILDINGPERMIT PERMIT# CONTROL#
DATE 3/1'719" VALUATION �i5,32.tz4) LOT TRACT 695-5
JOB SITE APN
ADDRESS 7&V50 4..AILE' i'-AMPICO 76r"134-14 i2
OWNER CONTRACTOR/DESIGNER/ENGINEER
1 11At, '10 x,'>,"'1°*d4';' LUIS "°it` D`'ITE `3:/kNCE & CONI!' '
4A. 1 I1.y a C t\' , 'R. 1 .a 14 `I._SV 6 t �r. a .
1332 Pt1KK VWW AVE ii103 � 3685 MIST ✓HOWF:1t
MANlHA I'! AN BEACH CA 90266 LA. OtTI " 1'A CA 021.2.53
(764})771-1190 CRL.ft 2.
USE OF PERMIT
BL ILDiNG
t1r'.�w�li S'.F.Lltu MA
t
R 17 1998
CITY
a
PL.AKE:WC ,"iF l4)1 -000-43q-2418 $It'•f4.U3
CON% 110K. 10N F FE 1 {1 WXA)-s t 8-4kM1 S Miss in
`aPtcO NCI NIC TION NIX - CON414 14)0-)4)4)-3111-000
t�s7NF.I1?(J(7r10N AND PLA, ("MCK.
LESS
PT I DATE I BY I DATE FINALED
LA NIA
25,32 3.21
x;13 f S1�
$000
WI N%
,.r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings 3
Underground Ducts
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 Wali 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 I I v
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
L
Final
UK* Notice (Perm)
COMMENTS:
VI i 1 Vi' LM �1VIIY I K
SUB -LIST
. �•I,JtSe� r
CONTRACTOR ADDRESS_1 � �v�••�'L.�
OWNER/ .-tr^pc., _ A.&t* Ce0_4A.- _ JOB ADDRESS 7R 504o -_..-F
This form shall be posted on the job with the Building Inspection Card at all times in a cnncnic-��n�c D:eCe.
It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that
are on this list are the same persons performing the work. Any changes to this list must be approved the
City. of La Quinta Department of Building & Safety, rior to work being performed by a changed.sub-
contractor. Failure to comply will result in a stoppage of work and/or the voidance of building perruit.
-
_
TRADE:
:.
::SUB'=CONTRACTOR'S
::NAME. `
'TYPE.OF
:LICENSE
STATE
CONTRACTO.R'S `
LICENSE
NUMBER ;
WORKER'S.::;
COMR NANIEr+
NUMBER`ON::FILE ::::NUMBER!
;`
CITY .:
:,BUSINESS
LICENSE
EXP:°DATE
GRADE/ :;:::....`.:>
EXCAVATE.:'.:,.-:.:
A/C -12
:PIPELINES`:.::: :::: ':;;>
C-34
CONCRETE
`FOUNDATIONS
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ASPHALT.: ;;.::"
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A
FRAMING
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B
7
STEEL/
STRUCTURAL
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C-51
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L�ata�3ooy-►o�7..Q
'MASONRY .
C-29
PLUMBING
C-36
LATHING'. -
C-26
DRYWALL ::
C-9
PLASTERING''.....*
C-36
HVAC.
C-20
ELECTRICAL ..
(General)
�i4�R?�wCll �
C-10
ROOFINGC-39
SHEET METAL
C-43
FLOORING.
C-15
GLASS/
GLAZING.:'. .
C-17
C-2
SEWAGE>DISP ..
C-42
PAINTING!' :,
:DECORATING;;
LVI.yC_
C-33
(,bti32.8
TIS.`::
C-6
CABINETS/.
.INSTALLATION-:.:`:..'.
:FENCING
C-13
1AND:SCAPING;<`.'..`
C-27
:PO:OLSC-53
OTHER :
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