0104-126 (BLCK)LICENSED CONTRACTOR DECLARATION
11 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
449153 IMMIX
�Date��=" tSignature of Contractor
` ¢ * OWNER -BUILDER DECLARATION
I hereby affirm under penalty (of perjury that I am'exempt from the Contractor's
License Law_ µfor the following reasom.: `
as`owne'r of the property,:'or my employees with wages a's their sole
compensation, • will do the work, and the structure is not intended or offered for
sale (Sec..Z044, Business & Professionals Code).
( ) • I, ass owner of the property, am exclusively contracting with licensed
contractor`s to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C. for this reason
r� 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).
() 1 xe tify that in the performance of the work for which this permit is issued,
I shall riot .employ any person in any manner so as to become subject to the
wo,rke'rs' ,compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code,,l'shall forthwith comply with those provisions.
Date: "% _% Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall'subject an employer to criminal penalties and civil fines up to $300,000; 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
Cg crect. 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) ✓7 �'* r ✓ *r{f'^'lDate
k -
L
BUILDING PERMIT PERMIT#
�
DATE ' VALUATION LOT 01 = TRACT ..
%j�
JOB SITE ' \
APN
ADDRESS
11 3 A"ifi1-MI>A VAL,1; F.10
.}
OWNER'• ti _
CONTRACTOR/DESIGNER/EN (NEER _
- T7c
MU S"!"EWARt.T
PAM 11 J'OUGY COMMUCIMOR .•
• .1'w ks e � J
31 w 1 l 1 1'A►M LAKE
C h 92'253
IND- 10 �,CC� - , CA ., ry ?J i
(76(l)342-6692 (MLO 4135.4
USE
��OF,
,,PERMIT
l,A L.YF OR��N��.yyt�.3ifL1'(",�Jq`]�'WITH H 3'*PI .AS'!'ERS tV1�:R 10'
�YA',MALL-1RJDN
,- $91Y0 Mt%:.M.14 ” '
ALI, M, CITY SbtNDJUtD
SFT, WALL 342.901.�
ESTDAAM1 W C09rOF COMIRRM3.70H
51239M
COWTRUC.'.i HM PSE 101-0100-418-000 31, i3
240TAT C;ONSTRU(.°`:II.(?N.Ak+1DPL WCAMY
9.Ca
.'`% PIM -PAID IT -
TOTAL FIC 1.'1' MS DUE 14OW
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPt.RATION
DATE
INSPECTOR
OPERATION
DATE
TINSIPECTOR
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. _�
Electric Bond
Main Drain
Bond Beam _ %
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test
Final j . O 2—
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)