9912-093 (BLCK)'LICENSED CONTRACTOR DECLARATION
I hereby.affirm under penalty of perjurythat I am licensed under provisions.of,
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and,
Professionals t;'ode, and my License is in full force and effect. -
License # `' Lic. Class Exp.. Date
0313-1/20(
D_ ate �rT-' 4` ignature of Contractor
OWNER -BUILDER DECLARATION.
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 th6'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 perjury one of'the following declarations:
() 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 isurance, as required by
'Section 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.
Mn'1. liis S 511»i'Si1t1.-111.!79
(This section need not be completed if the permit valuation is for $100.00 or less).
(') I certify that inthe performance of the work for which this permit is issued, `
l.shall not employ any person irf'any manner so as'to become subject to the
workers' compensation laws of California„and agree that if I,shouldI become
subject to the workers':compensation provisions•of SectPn•3700 of the Labor
Code,_l shall f rthwath comply wlth`those prov_islon§.
Date: f A,Fplicant
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. �.
y
IMPORTANT Application is hereby made to the Director of Building and Safety
fora permit subject to,theJconditions and1restri6tions set forth on his
application., ,
T. 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.
: 2. Any permit issued as a.result of this application becomes null and void if
• work is not commenced within 180 days from dale 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
construction; and hereby authorize representatives of this City to enter upon
the above-mentioned property for -inspection pur'p`oses ;
Signature (Owner/Agent) '” ^ Date
' BUILDING'PERMIT•
' PERMIT#f+
DATI VALUATION ', LOT
�4y TRACT
JOB SITE
ADDRESS , W�i� �8C1 A;U
`
APN
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CANKD :Y. & -COAP KNY
CAS ,bVD.Al <ti. C.tj'MPANY
1:570 BRtit:►Kk L;r..)W'.i3RIVE,; Si,lRIE 208
►}"r'0 i i�i3Cii iC: °%,t:i��V Di�IVE, aJTV9 208
S.AN''1:t1AINA CA 92705
SA,'vIAMIA Cts.
92705
°
(714)751-9151
M4 4.485.
j
USE OF PERMIT
zrf'-,v, ,i1R_ L BUILDING
295 L.r., 6'{319. .i1:.F.'5`( GARi F-14 WALT • ei�CG ST �1Nt)tkRD
6 F!" WAF *J.
295.00 LF
`
S VT. ANAi.L
11.0 LT.
,V.9x.6.1Fakirolt
V
_
t:U.iVS': RUC"l710N FRE 101-00t?414-000
$99,00
'03 ms'RTTC
€��C�
�
$9Q47
ID'S I'Ii�-:E'�1FY? FL.RC
:a °.a'd,'ite r: 1bE9'1' i • 1•;; DUL NOW
RECEIPT
DATE
BY (
DAT INALE r�`1.(,
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
F,)rms & 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 --p—b
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: