0112-039 (MISC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of nerjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Dat lo 4z; Signature of Contracti
OWNER -BUILDER DECLARATION
1 -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 sole
compensation, will do the work, and the structure is not intended or offered for
sale (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
Code).
I am exempliunder Section B&P.C. for j�K'reason
Date Signature of Owner
'oe Y
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
�,J I have and will maintain �a.certificate of consent.to self -insure for workers'
compensation, as provided forby 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 insurance, as required by
Section
ection 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 elAT&F :Policy No.
3
(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
workers' compensation laws of California, and agree that if- I should become
subject to the workers' compensation provisions -of Section 370Q.of the Labor
Code, I shall/forthwith comply With those-taroV rsions.
Date: X Applicant-
WarninglolFailure to secure WorkersCompensation 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.
2. Any r.'�p
permit issued as i 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 work1for 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-metitioned property for inspectp'rr`purposerk;4._
fT Signature (Owner/Agent) Date
A
BUILDING PERMIT M IT #
DATE VALUATION LOT 0.1124-09 TRACT
Mu* A 2.9994-2.
JOB SITE 0 0 -374 V 1, A P 0 IM, CO -7N
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN (NEER
A
RAN01-10 CAPRITIRANO DTfVJ.,1k1- NMIEN"f RAI -11 M10 CMICITRANO IORIVE L
96tr7 COMMY CLUS DR 0201
B9RWX,0A'DU9F,VS CA 92201 R Ke khf UIDA.?. IIN: 0,A, 92201
(760).345-7755 MILD 190
USE OF PERMIT
TEMPORARY CONVRUCTI-CON TR.A11XR',PF* ',WUP 2001. 424, TRAcT.
108044,
VAIATATIi'M
E5rf_TA4t1XD C09r OF CONSTRITMOF
PZWKIC FIM SUNWARY
TWENP CaNSTRUCTION TRAILE) 101 -000-423-000 $200.00
KYWYCAAL 00149MU MON kNkTD PLAN C_WZ%
LIF3.151 FRE-PtMPT11231
TUTAL MMT171"FES ]ATENOW
RECEIPT I DATE I BY
W
I
W. 1 0 0
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
O.K. to Wrap
F.A.U. 0—j—
Framing
Compressor I
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
.Final I
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service fl 1AAri
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)