9904-152 (RER)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that l am:licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14yW : Professionals Code, and'my License is in full force and effect.
License # Lic. Class Exp. Date
�•w rte- }, 470699
oZ ZDe L#_ ' Signature of Contractor-• ��
J U � OWNER -BUILDER DECLARATION ,
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ �n/^-� � ' 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).
`, ;'• ( ) ,1, as`owner of the property, am exclusively contracting with licensed
contractors to construct the -project (Sec. 7044, Business & Professionals
i• Code). '
U-)• O I am exempt under Section B&P.C. for this reason
Date Signature of Owner
U Q ` .< WORKER'S COMPENSATION DECLARATION '
-,o'_ �I hereby affirm under penalty of perjury one of the following declarations:
"r <- () I have and will maintain a certificate of consent to self -insure for workers'
X •LL] LL compensation, as provided for by Section 3700 of the Labor Code,'for the
performance of the work for which this permit is issued.
ie' (50 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
•.'0 .� permit is issued. My workers' compensation insurance carrier &policy no. are:
�f Z Cartier Policy No.
C3 cour;FNEAGUI, 14'WC-0, M, 11.1400
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 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,thosse provisions.
, /Date: t'•� - 1 ' • `a ;Applicant—
Warning:
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
f ` ...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.
r(57 2. Any permit. issued as a result of this application becomes null and•void if
work, is not commenced within A80.days from date.of. issuance of such _
permit, or cessation of work for 180 days will subject permit to cancellation.
1, 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 x
the above-mentioned property for inspection purposes.
Sig a ure (Owner/Agent) ._ (!X't ^"' '-` Date
BUILDING PERMIT PERMIT#
DATE 4f fvq!) VALUATION tS�i'ililr.11 ! LOT TRACT
JOB SITE
ADDRESS 55-489 SOi#T>t�E+ R HILLS APN - K
OWNER CONTRACTOR/DESIGNER/ENGINEER
11130 F C HAPtvlAN AVE STE 100 55-960 Mik BLVD
ORANGE CA 921486 I�A QUlAlTA CA. 9 253
f,'7iQlti33-' C� (INIL I: M181
USE OF PERMIT
YCESMlri�t" 'IAL £tEiNIOfYEL
VALUATION 5'.000.00 LS
E.gT31ZIMI) COST IOP CONS;n RIUC `ION e,t0,0'E)
119wiT FEE SbiMMA.RV* ,
PLAN C` I CK FFX $.01-000-439-3.19 535.0
t.3E'eti;PilY'ALF1_7131..�0
101 4V) -420 -OW $15.00
S`l�tfiNt: Afs:Yl'IC?'I�t N#?L, - z2L•S1L7 tfii-t► l;-?ill-rl£flf $.50
t
EC' $144,00
- - `
TOTAL VEMAMI' F"Ir+ EN >0I<Ill'a NOW - $144.04;
RECEIPT DATE BYy; DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation JE
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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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)