0006-143 (BLCK)r
LICENSED CONTRACTOR DECLARATION
°'ir`.lereby 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 '
.59T561,1i3 " U�l3112f.
ate4 Signature of Contractor t
f
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. (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). `
O 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.
(,k 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 I'1pmork1'T C'OMi 1148 Policy No. 360.1.111®-14199
(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;agreethat. if I should become
subject to the workers' compensation provisions of Section.r3700,of the Labor
Cole` 1 sFiall/fo hwitomply with those provisions.'
�q te: r f .f i h C{'APPlicant
1
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
any permit issued as a result of this applicaton agrees 4o, & 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 l5ove-mentioned property, for inspection purposes.
`Signature (Ownee/Agent) �+ .��' Date t
BUILDING PERMIT PERMITk
DATE /' f ,.� VALUATION LOT . O( -1.4 TRACT
S1.275M 26152
JOB SITE
APN
ADDRESS 47-64M WA, MONTA,�[ A
( si/�/
_ _
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CM111',iAY C010ANY
CANADAY &, COMPANY
15'71.11ri1.�ooki-iouow mim., uuff1.�' 208
1570 BROC MMID1 i SSW DFAVIE, R.71M 208
SWMAW11 CA 92705
SANTAAMA CA. 9270S
(714)751,9131 0370 4485
USE OF PERMIT
171 LIP. 61 MON a&RDN..3d WALL, - ORC:O STANDARD
6 FT, WALL 171,091,E
ES'7f "TKID COST OF C:OX'tTM'tTMIO.N
4�7�.t1t3.
C ONOTRUCTJON FEE 101.000-416-000
JAN PMPAID 1 S
$0.00
TOTALPEPMUTIfFREA DIM NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 O—bO
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final Z Z
Gas Piping
PLUMBING XPPkOVALS
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)