0002-367 (DEMO)t w. LICENSED CONTRACTOR DECLARATION _
I hereby affirm under penalty of perjury that I am licensed under provisions of
H,'Chapter,9 (commencing with Section,7000) of'Di4ision 3 of the Business and.
04 W Professionals Code, and my License'is in full force and effect.
License # ` � Lic Class Exp.; Date
CD O � ' f : _B95€ii' C20 C sa'1s ii I3 Ir`'20i
z o Z r— t/Date f Signature of Contractor f�
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u i.— C) q OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of.perjury.that-l'am exempt from the Contractor's
~ a License Law for the following reason:
Z ( ), 1; as,owner of the property, or my employees with wages as their sole
compensation; will do the work, and the structure isnot 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). ,
NO I am exempt under Section B&P.C. for this reason
N Date Signature of Owner.
U—=, Q 'WORKER'S COMPENSATION DECLARATION „
C) �' I hereby affirm.: under penalty,of perjury' one of.the following declarations:
F -m Q O .I have and will maintain.a;certificate of consent to self -insure for workers'
' X w - compensation, as provided for by Section 3700 of :the Labor Code, for the
m JJ Q performance of the work for which this permit is issued.' `.
Q CJ ( ) I have and will maintain workers' compensation 'insurance, as required by
Q 0 -
Section 3700 of the Labor Code, for f 'e performance of the work for which this
d'LOF-w permit' is issued. My workers' ,compensation insurance carrier & policy no. are:
,t' zCarrier L'+��1:,it , ;Policy No. -
Q . (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
worker5,compen sation laws of California, and agree.that if I should become
subject to the workers' compensation provisions of Section 3700 of_the Labor
Code, I shall forthwith comply with'those provisions.,
Date: ,!`jAD61icant
V
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 to, & shall, indemnify
& hold harmless the City of La Quinta, its,officers, agents and employees.
1 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
constructlw:and :hereby authorize representatives ofthis City to enter upon
the above mentioned property for -inspection purposes.
i
ySig'nature (Owner/Agent)'' t !_ r Date '):'9 -
V
. PERMIZ�
"BUILDINGPERMIT
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DATE. VALUATION i.LIoI LOT, + TRACT 't
JOB SITE
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APN
ADDRESS
OWNER R� F
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CONTRACTOR / DESIGNER / ENGINEER
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7895 .A:gNiV41)ALE' AV;E
PALASE R ,.
(L�' CA 9,1211
D7ES.E-10' HOT SWING, CA 1922140.
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USE OF PERMIT
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PERMIT FE El SUNFAIAKV
f�f�'tt3i t'� 10N i�i'3s" -101-600-423-OW 4S.Ot1,
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RECEIPT
DATE
By ; .
DATE FINALED
INSPECTOR 1, i
.
,.
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
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
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: