0010-156 (BLCK)LICENSED CONTRACTOR DECLARATION
I k6reby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing mmencing with Section 7000) of Division 3 ' of the Business and
,,;:Professionals Code,and my,,Lice . nse is in full force and effect.
I , 1. U - 06. Class
License # Exp. Date
Signature of Contractor t actor
V
OWNER -BUILDER DECLARATION.
hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
ti
( ) 1;, as owner of the property, or mV em . ployees with wages -as their sole
compensation, will do the work, and the structure is not intended or offered for
sal&'(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
d6de).,
()'I am exempt t under Section ,B&P.C. for this reason
Date" _Signature of Owner
WO I RIKER'S COMPENSATION DECLARATION'.
I hereby affirm under penalty of perjury-, one of the folldwin6 declarations,:
I have and will maintain a certificate of. consent to self;insurefor Workers'
corfipensation,as provided for, liy 'Section 3700,of the'Labor Code,,f or the .
performance of -the work for which this pe'rimitis issued
I have arid will maintain workers' compensation insurance, as required by
Sbction 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My w6rker's' 66mpensation insurance• carrier policy- no.74re:
Carrier Policy No.
VITAU FUND'
(This section need not be completed if the permit valuation is for $100.00 or less):.
O 'I certify that in the performance of.the work for which this permit is issued,
shall not employ any person i6,any manner S6 as to become subject to the
workers' compensation laws .of California, And agree that, if I Should become
subject toAhe workers',cbmpensation provisions"o'f Section ction , 3700'of the Labor
Code; •I forthwith comply with thgse provisions
[?afb;" Z 4 -: 1 �2 ��4Applica int
1
Warning: Failure to secure Workers' Co -7
mpensation coverage,is unlawful and
shall subject an employer to criminal-penaltigs and civil fines upto $100,000, in
compensation, the cost of compensa:6n, damages as provided for . in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Appli6ation is hereby made to the Director. of Building and Safety
for a permit subject to the conditions and restrictions set forthon, his
application.
1. Each person upon'whose behalf this application is made &.each person at
whose request'and for.wfiose benefit work Js performed under -or pursuant,to
any permit issued as a result of this app licaton 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 inform I ation is
correct. I agree to comply with all City, and State .lav�s relating to the building
construction, and hereby authorize representatives of this City to enter. upon
the above-mentioned property for inspection purposes.
ignature (Owner/Agent) Date��"7
PERMIT#
BUILDING PERMIT r
TRAC -
DATE VALUATION LOT T,%'
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER EN (NEER
P 0.130 X. 37 IF,?
N Co- 92253
1A QODkr.rACA
PAF M. DIME RT 9.2,261,
'760)r -1- 9 CT 6076
M �55
_31.if
USE OF PERMIT
7
15 ?_Tr: t 241 k181'A1N;NCD BIDCK WALI, - CITY ST.A141-JARD
4 ff., WALL 46:00 V
FISMA"IRD COST OF COT191311-rYcri-off
88040
CONSTRUCTION IRIS 101-066-418, -000 $23,00
MM -IX. M COMBYRUMICAR AND PTAN CTILX.
s2aoo
US'S 1YRF-PAMA'"'.3
so.00
TOTIALL DIM., NOW
WAX)
RECEIPT r
JDATE
ID NALED/,_
T11
I INSPECTOR
INSPECTIONRECORD
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings p–v
Main Drain
Bond Beam /�y�./��
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final0—p j
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:
-