9904-025 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty -of perjury that I am licensed under provisions of
'Ch-a'pter 9 (commencingwith 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
591 j6 1,; .13 t/2(X
03
ateSignature f Contractor
- o
I -
OWNER -BUILDER DECLARATION
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'(S'ec. 7044, Business & Professionals Code).
1, as'owher 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 fierebi'affirm under penalty of perjury one,,of the following declarations:
O 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 -
()4.,l have and will maintain workers' compensation -jnsurance, as required by
.46tion 3700 of the Labor Code, for the Performance of the work for which this
permit is issued. My workers' compensaition insurance carrier & policy no. are:
Carrier. Policy No.
MACAU-. INS CO
(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 ny 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 8700,of the Labor
CoVI sh alVorthwith comply with those provisions
t( Applicant
te*
VWarning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer io'criminal penalties and civil fines up to $1 . 00,900 in
additibn 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',conclitions 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 applicator agrees to, & shall, indemnify
&.hold. harmless the City of La Quinta, its officers, agents and employees.
4. Any permit issued -is 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 I ve 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, . aAye-mentioned property4& inspection purposes.
ignature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS' 47_1jS0 VJ,&-.'W10NFA1NA
OWNER CONTRACTOR DESIGNER ENGINEER
CANADAY&COMfIANY CANADA . COMPANY
I570,B1k00K110L1XJW-DR1VJ,? SCJ TE 208 15-70 BROOK1401.60W DRIVE, SUITE 208
SAKI'AMA. CA W2705 SAMM ANA CA 92705
CUP. 1U85
USE OF PERMIT
C3 RIN F FL A L B Ul IL D. -I N 0
171) Lli,`. X G,'240 LIZ. X 1& 16 L,V. X 41 BLOC X' WALL (ORCO
STAT OARV)
6 �'T- WAIA. 170,00 LF
5 r -t- WALL 20.00 LF
.4 Pl. WALL 16.00 LF
1?,SoTXA1.ATE D COST OF CONS'AMMMON
PERINITT FEE SUMMARY
C0NS*FfttfCT(0N FEX 101AX)0418-000
A
1S,.UBM7W, AND PLA�j CEfECK
LUS PKE'J'AID RES
PX INIAT F,FTS 01TENOW
TOTAL k
RECEIPT DATE BY DATE FINALED
PECTOR'
41939100
$0.010
. I .
$72.0
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
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
Electric Bond
Footings
Main Drain
Bond Beam ` 9
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)