9912-096 (BLCK)LICENSED 'CONTRACTOR DECLARATION
I hereby affirm under penalty'of perjury that I am licensed, under provisiohs.of
Chapter 9 (commencing with Section,7000) of Division 3 o the Business and.
Professionals Code, and my -License is in full.forceand effect.
Liceriab # i 'Lic.'Olass' Exp. Date
..,59*610200201
/a, 4
4
Date iSi�nature of Contractor '4
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:..
1, as + owner of the property, or my employees with wages as their sold
compens . ation,,will do the.work,'and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of.the,proper ty, am exclusively, contracting with licensed'
contractors to construct the project (Sec: 7044, Business & Professionals
136de).
( ) f am exempt under Section • B&P.C. for this reason
-Date Signature of 6wrier
WORKER'S COMPENSATION DECLARATION
I hereby affirm - under penalty ;f ' pqrjury one •of the following declaratidns-:
-1 have and will , maintain a certificate of consent to,self-insure forw6rk6rs':
Compensation, as provided for by Section 3700 offfie Labor' Code, for the'
ped6rmance of tlie'work for which this permit]s issued.
!)-Fhave and will maintain workers! compensation insurance, as required by
Section 3700 of the -Labor Coft, for the performance of the work for which this
permit is - issued. My.workers' compensation insu'r.ance carrier'& policy I no. are:
Carrier �Policy,No
I . I . . . " " (10, 17
�0110 I INS ---t 1 -9 -
(This section need not, be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance mance of the work for which this permit'is issued,
I shall not employ any,personlin any manner so as to become subject'to the
workers' compensation law's -of California, and'dgreeithat if I should become
subject�o tl�e workers' compensation provisions of S ctioni 3700 of the Labor
Code', shah -f W th%comply with those provisio_X.,
Dale Ppofi6ant
Warning: Failure'to secure. Workers"Com pen sation coverage i i s unlawful,and
.shall subject an employertP criminal,ppnaltiei 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 Applicationis h6reby made.to the Director tor of 6uildi6g and Safety
ty,
for a perhift_subject to.the conditions and 'restrictions setr'forth onLINS,
application.
1. Ekh 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 harr-hl.ess 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 withall City, and State laws relating to the building.
construction, and hereby allth . orize reprfs6htatives of this City to enter upon
e- I i
the above-mentioned property -for ins ' pe tion" pu rpos - es.
�7
Signature'l(Owner/Agent) Date -
PERMIT #
BUILDING.PERMIT
VALUATION LOT TRACT
DATE - 4,144.40
4
JOB SITE
ADDRESS 4-145o "k iRA
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CAN,'VDJA,Y & 001N.VAINI Y
& (,'0MPA1NY.._
I 570.8R001W.10LL0W.D!;U VE, SUMS 208
1570 RK001CHOLL0 DR [VE, SUITE 208
SANTA AVA CA 92705
SANT.A ANA (,A 9;r105
CKM .448.5.
USE OF PERMIT
152 L.P., 0(fl) & $6 L. AM 04=04 W!=, 0RC0,3TWJ-XM4
6 FT. NVALL 152.00 LF.
svr WAI:t. 16.00 Ly"
079 V0N6iTTW T r f f
-NFF
colo nj Tcrio 101-,000-419-01EX)
T(YFAL' Ek -'F_FTT_S DUEN0W
RECEIPT
DATE
BY?E
IN
��[
INSPECTOR. -
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
- BUILDING APPROVALS
MECHANICAL APPROVALS
Set BL-cks
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
Footings —� —
Electric Bond
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:
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