9710-103 (BLCK)II LICENSED CONTRACTOR DECLARATION
:U) I hereby aff irm'under penalty, of perjury that I am licensed under provisions of
17- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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N W Professionals Code, and my License is in full force and effect.
C) License # Lic. Class Exp. bate
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r- 591561. B
Z r— Date9 7 Signature of 'Contractor
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OWNER -BUILDER DECLARATION
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LU Uj I hereby affirm under penalty of perjury,that I am �eixempt from the Contractor's
~7 a- License Law for the following reason:
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Z* 1, as owner of the property, or my employees with. wages as their sole
compensation, will do the work,..ghd 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
contractorsyto construct the project (Sec. 7044, Business & Professionals
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am exempt under Section B&RC. for this reason
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C\J Date Signature of Owner,
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WORKER'S COMPENSATION DECLARATION
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z I. hereby affirm under penalty of perjury one of.the following declarations:
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F-; 0 have and will maintain a certificate of consent to self -insure for workers'
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X W — compensation, as provided for .by .Section 3700 of the Labor Code, for the
0 _J, _J performance of the work for which this permit is issued.
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(},) I have and will maintain workers' compensation insurance, as required by
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Section 37.00 of the. Labor Code, for the performance of the work for which this
t Il LO permit is issue I d. My workers' compensation insurance carrier-& policy no. are:
It z CaTier Policy No.
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0 UNICARFONSCO SA -50- 11,96-14179
< (This section need not be completed if the permit valu ation is for $100.00 or less).
J ( ) 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
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subject to the workers' compensation rollsion§ -of ection 3700 of the Labor
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bode, 1. shall forthwyth Comply with ,7Ke i
Date: hw")-V/`��/ Applicant— 7170 77�.
Wairfi6ng:.Failure to secure Work 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 Section3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Applic ' ation is hereby made to the Director of Building and Safety
for a permit subject to the 'conditions' and resfiictions' set forth on hip
application.
1. Each person upon whose behalf this application is made & each person aff,
whose request and formhose benefit work is performed under or pursuant t.6
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 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
his 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 authorizerevese - n!�tivies of this City, to enter upon
'
the above-mentioned propertl�f6-ro.'iy'los'pegtion e/purhp'oses.�.
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Vsignature (Owner/Agent) Date
BUILDING PERMIT PERMIT # 97n0-103
CONTR
DATE " - VALUATION LOT' TRACT
. I - . 1 Z1OL# 9
3
JOB SITE APN
.ADDRESS
47-7%V1AFLORENSCE
OWNER CONTRACTOR/DESIGNER/ENGINEER
:CANADAY'.&CQKPA.W CANADAY & COMPANN
1570 BROOKHOLLOW DRIVE; SLUE 208 1570BROOKHOLLOW DRIVE, SUITE 109
SANTA ANA CA 92705 S.ANTA ANA CA 92705
(714)751-9151 CBL# .4485.
USE OF PERMIT
,n=F Y& 751Y 41 ORCO BLOCK' WALL
5FT, WALL
4 FT.. WALL
222;00 LF
73.00 LF
ESTIMATED COST OF CONST RUCTIOIN
PERMIT FEE SUIWMARY
CONSTRUCTION FYX IW -000-418-000 $90.06
w.
4
ED5 .74
�raTALcoNs-muc-nolq:AND PLAi4cuEe-K, _S90.00
LESS PR'9-PAID FEES
OCT:.2 4 1997.
TOTALPERN41T FEES DUE NOW. S".00,
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(7 V 0F,
RECEIPT DATE BY/ DATE FINALED INSPECTOR
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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.
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 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
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: '
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