0101-344 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury 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
4.78689
Date • r� f"� Signature of Contractor titi
OWNER -BUILDER DECLARATION
I hereby affirm.under penalty of perjury that) 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
easonDate 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.
j4,)t1 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:
Carver Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(. ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any -person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shaPl��l, forthwitjt comply with those provisions.
Date:.t `ZA Applicant
Warning: Failure „to secure Workers' Compensation coverages unlawful and
shall subject an employer to criminal penalties and civil fines, up+to�$l dO,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 tpo
any permit -issued as a result of this applicaton agrees to, & shall, Indemnify
& hold harmless.the City of La Ouinta, Its officers, agents and,employees.
2. Any permit Issued as a result of this application becomes nulland 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 focartcellatlon.
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-mentloned property for Inspection purposes,
Signature (Owner/Agent)t� �.,."""" Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01.01-344 TRACT
4-7 x4 '�3r3
JOB SITE
ADDRESS
APN
O ,t^p D
OWNER
CONTRACTOR/DESIGNER/EN INEER
C °� 171RY Mk�2rCANTWE'C.,,.TNOOT T, CORP,
CEN 171M Y" AWNICA � � x �i ? . (::c9!°
1s QiUMA- CA 922533
Imo` Q1,tN1'A CA 922W
(160)SfA-56112 IA 54.M
USE OF PERMIT
SINGLE FAAEX IMLLM
;M-) .. LJOT 47111,A14 2A -. Pf_l",IY VOMS NOT 'INCLUDR, al )QL
WL+f-,1POOI,WA OR APPROACH171WKWA.Y. 75% PLA Cmwr, In
i#:EDUCTION FOR . F:f1UVr1PL1U )S"5UA0gC • OF S.fii:ME P:llaA18 't'ii'PE
"£1`Lkar WAS'fl'RUVITIOC$ 769A SF
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OARAGWCARPORT
Y -Fab 6:`:lf ra s"
3+1.A9.1ef C H.WX FLS: 101.000-439-318
it laflll��iflCAF,F� ? 101-Wt3(1.421.000 $92;9
M.lXTRICAL FRE 101 -000-4'
PL1JMl0D.gQFXT.t ", '101-000.419.000 51,69.7
STA0Nl0 M0TJ0N-+M� RZSID 10'1-,=-241 -000
t11tAatlld3Ata ` .01-0101.423.000 b��iitr
9111V 'WPM AT?A C1'I° liL
Rp rl 1IN't J'J.',P1,IL f omam�"L3'1.ft7%i'. '3.y1:`./t�p'1��94�Jt f"n��R�iiq"�K
$3,398'.2,6
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RECEIPT
DATsEyp
BY
DATE FINALED
INSPECTOR
31 `
P:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs �G,��i
Forms & Footings `�_
Slab Grade 2
Steel
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Roof Deck
gmC
Exhaust Fans
O.K. to Wrap
Framing
u I.Z ¢+PTS
ly (�� �QyG
F.A.U.
Compressor
Insulation
H_� Iti C &�-4
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall- Int. Lath
Final /7`/
BLOCKWALL APPROVALS
Final
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
Zl (&P C
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
tp
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
Sub Panels
Exterior Receptacles
9_
G.F.I. PY
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) � /