0010-071 (RER)N
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
i'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
71 *155.3
,pate-"=�`l�;�c Signature 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 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) 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 isissued.
( ) I have and will maintain workers' compensation insurance, 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.
EXEMPT
(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 3700- of the Labor
Coyle, I shall forthwith comply with those pI4visio
ate: ' P ,r 1 a.., A licant r.
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, indemnity
& 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 date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
certify that I have read this application and statethat 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 in Ctio9;Ourposes.
J'
Signature (Owner/Agent) -�✓ Date +�
V —.-�
BUILDING PERMIT PERMT#
DATE t VALUATION LOT 10-071. TRACT
JOB SITE
APN
ADDRESS '
48,-' M. FMW.1f1FXQW.P2Z D91[W.
- ..
OWNER
CONTRACTOR / DESIGNER / EN (NEER
I I/M COR,VAN
010101FIC: C(9CTMUMON COMPANY
284'5WAI4 R3�i7i1:'ATR.+-'A%+
rt24WA�,T�S TIN4iTON MRAU 3UM Vii
LIr,:4 FOPM MXT 53911
: ALM -DI Mxi
(960)341.2974 CIMA 6306
USE OF PERMIT
.AYAIMM.
.A1,TTKR A'I I0N3 ,i1fD RICRAIPS TO EXISTI140 RL?30,)r1 dr:t11 AS PER
d'a43tPROV&D F"t9arNS ONLY
VALUATION lf4700.(lft IS
OF COPI )i'RUar`.!RM
pr -RAM VFW RQ.MM11t'RY
PW4 CIRECK VIER l p ;-CrCrtf�3��aci R ffi163 7�
- _I
CS' NIrft"F:UCTIONI I1199 flat-CUU-41 f• rCf) $1 3.0(?
M'Et"HAMCAL, FEE 101.000.421-000 ss3.S(I
X1.1tw"ll°F21C.Af.,FER 04.04
t'Li1i�T'.tlTat9 �fL 1 Ct'1 r4"�Jn-4.13-C.�O 3�3,t1G
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SM- i'0Yl.`AL 00IMP C;'1.`t0 AND iyi.diX 05'1i1016
U4' 41. It
TOTAL "K 49T F-12-1-4 DUE NOW
REtJE1PT
DATE
BY f
DATE FINALED
INSPECTO
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.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final?OOL IS S, PAS
steel-- - - -
Set Hacks
Electric Bond
_
Footings
Main Drain
Bond Beam
_ _
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
_
Gas Piping
-
Gas Test
Electric. Final
—�
Waste Lines / d �a-ti=V
Water Piping
�� Neater inal
Plumbing Final
Plumbing'Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
_
Sewer Lateral
Pool Cover
Sewer Connection V —
Encapsulation
Gas Piping
--
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTMAL 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
Finnat
Utility Notice (Perm)
ARCHITECTURAL INNOVATIONS
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