0011-059 (SOTB)r ` ' 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.
License # Lic. Class Exp. Date
OMI
Date �� % Signature of. Contractor
zx/�),3
OWNER -BUILDER Dg LARATION,
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 Iperjury '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. 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
permiVis' issued. My workers" compensation, insurance carrier & policy no. are
Carrier Policy No.
MAHM,014T COUP D42 �1"' '�•1 k�3�t.� d�! k ?�+ , ;.
(This•sectionneed not -be completed'if.the permit valuation is for-$100.00.pr less).
(r") 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 protions '+f Se ti rf 3700 of the Labor
Code, I shall forthwith comply with tho tsi
Date: /� a Applicant
7,/ ••.. .-�. �. a tr/
Warning.• Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil'fines up,to $100,600,;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.persoh 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, oomply with all City,'anpt- tI 4s relating .to the building
construction, and hereby authoriii r pre en v sof this Citylfo enter upon
the above-mentioned property for insS ecctf'O p rposes.
Signature (Owner/Agent er r�.� Date K"
' BUILDING'PERMIT i PERMIT# °
DATE VALUATION, LOTS Qj TRACT' ,-
JOB SITE
APN
ADDRESS
47-6 _5 WAMO.NTAXA.
Ji'' -• ` Li'
OWNER
CONTRACTOR/DESIGNER/EN INEER "
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d ,WADAY C1 WAIR, Y
c"..RNAi: AY &, COMNWY ,.
17480 E. 06
1°7480 E 1'%7. L1 OT. 910
CA . 921130
'c € S17�1 CA '� 1€ A
C,714)508-4440 MT44 4485' °� +
USE OF PERMIT
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RECEIPT
DATE.
f
BY
DATE F
INSPECTOR
p1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _
Forms & Footings /Z'�j'I�
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final /Z�.S--ev ��-
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
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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