9912-095 (BLCK)LICENSED CONTRACTOR DECLARATION
LICENSED
I
1 he eb a under
penalty,6f perjury that I am licensed under provisions of
affirm
Chapter
hereby
; 9
p�
ha ter (commencing with Section 7000) of Division 3 of the Business and
'Ofessio,als Code, and my License is in full force'and effect.
License #,. Lic. Class Exp.. Date
5.9,1561 0313,1120it
Date '7-7/ gnature of Contractor
OWNER -BUILDER DECLARATION
I hpreby.airni under penalty of 'perjury that I am exempt from the Contractor's
License Law for the following reason: . I r ' . N . . .
( . ) 1, as owner of the , property, ormy emRloyebs with wages as their sole
compensation, will do the -wor work, and the strubture'.is'not intended or offered -for
sale (Sec..7044,,Businesg & Professionals . Code).
1, as owner of the* property,am exc* lusively contracting -with licensed
contractors to construct the, project •(Sec; 7044, Business & Professioirfals
Code).
.1 am exempt under Section B&P.C., for this reason
Date Signat6re of Own6r
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:.
O I have and will maintairi 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' 6ornpensation insurance, as required by
SeLlion,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 Policy No;
W.11ONT MA41)S S*P'50 - 1 :100? 14 OV .
(This section need not be completed if the permit val6ation 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.agree,that if 1:should become
subject to the wbr 6rs' compensation provisions -of Section 3700 of the Labor
I
Code, I
W hos�eprovisions.
�s�h 7fo rt�
J_ t�% with t
Date: 'Ap licant
Warning: Failure to' secure Workers', ComperiSatio'n 'coverage is unlawful and
shall- subject ah qmployerto 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
fora permit subject I to the conditions -*and. restrictions striptions set ,forth on' his
application.
1. Each person upon wh(5se behalf this, applicaiion'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.
2. Any permit issued as a result of.this application becomes null and void if
work is not commenced within 18 . 0 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 applicition and state that the above infor-mation is
correct. I agree to comply With all City, and ' State laws relating to the building
construction, and hereby authorize representMives of this City to enter upon
the above-mentioned prope rty_foriii_s"pecti'q_pNpu rRoses.
* 7
Signature (Owner/Agent) Date 7-
N -
PERMIT #
BUILDING PERMIT
-,- -t
DATE VALUATION 57i75 LOT 91_,: TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
4011. A 0, A Y & 10 i..I I NY
CAMADAY & COMPANY -
.157f)i4ROOKliOLLOWDRIVI-..,sr—Tfrr4208
137.0 BROOKliCALLOW'DRIVE,' SUfPE 208
SANTA"AN.A. CA 92105
$A91AANA CA 92705
C;9s.,# - 4485 -
USE OF PERMIT
GE NE.RACURLD1140
WO LX., 6(19 iii 35L.F. 5'(14) GARD914 WAU- OR00 •SIANDARD
r) FT. IWAU. 190-00 LF
5 VT. WALL 3100 LF
ITISIMIM1.1leD COST OF
".57.75
P ER Wfil' r, 9 R S TJ 1% ON I A R Y
CONSMUCMUN FEE 10140 418-000
et 8 4f 0, TA L C ON S_ r1k X71, 0 N AN 0 PLAN C H F C. K
-LESS PRE-RAIDFJEES
P.M.
W 44 DUP
WCAUPE; WIT FEI_'� NOW
RECEIPT
DATE
1BY
DAT I ED
JINSPECTOR
f.
Y
L
INSPECTION RECORD
1 OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
r 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
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
Water Piping
Heater Final
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: