0006-134 (BLCK)LICENSED CONTRACTOR DECLARATION A �'
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 arid
P,rofeso�ionals Code, and my License' is in full force and effect.
License #Lic. Class ° Exp Date "
y
/ate
~' Signature of'Contractors It
OWNER -BUILDER DECLARATION _� r'•, ,, i
I hereby affirm under penalty of perjury that I am exempt:from the'Confractor''s
License Law for:the following reason:''.
( •) I;_as owner of the property, or my.employees'with' wages 'a's their sole
comperisation,-.will do the work,�and the structure is not intended or offered for
sale (Sec. 7044; Busihess & Professionals Code):,
( ) I, as owner, -of. the property, 'am' exclusively contracting with'. licensed
contractors'lto' construct the project (Sec: 70.44,, Business &-Professionals
Code): z
O I under Section' B&P.C. for this reason
am exempt `
Date. * Signature of -Owner x.
WORKER'S COMPENSATION DECLARATION,,'. {
I hereby -affirm under penalty of perjury orie•of -the following. declarations'
() I have and will maintain a certificate Iof.conse'nt to'self-insure for'workers'
compensation,, as provided. for. by, Section 3700 of the Labor Code,,for .the
11 e
performance of the work for which this permit is issued r .1 , '
( 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:
Garner I�MONT C'ORAP rNs , Policy No.
ins - 0-4179
(This section need.not be completed If the permit valuation is for $106.00 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 astobecome subject to the
workers' compensation' laws of California, and:agree,that 'if I -should become
,subject to the workers' compensatlon'provlslons oftSection 3700 of the Labor
Code hshall,forthwith comply with those. prowslons x
71 Applicant' `
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, 6n 'his
application:
1. Each person upon whose behalf this application.is made & each person.at
r 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 applicationbecornes.null.and void if
work is not commenced within 180 days ;from date.of• issuanceof;such .
=permit,or cessation of work for 180 days will-subject,permit to`canceilation:
I certify'that I have read this application and state that the above iriformation is
correct. I agree to comply: with all City, and State laws relating to the Building
cons .ruction, and hereby authorize rep,sesentatives of this City, to, enter' upon
the/above-mentioned property forinspection purposes
gnature (Owner/Agent)
PERMITS r
BUILDING PERMIT
_>
.
DATE VALUATION LOT! ' TRACT
7, ,12 > . $41WOM aces .
JOB SITE
APN'
ADDRESS 78
,-9W VU, FLORENCE
OWNER
CONTRACTOR/DESIGNER/EN (NEER
C.AN DAY Ak-COMPAN'Y'.
CMA4DAY.' & CO:M)ANY .
1570 '..Q0k1-T01 W i)RNL? SUNS 208
15'70 BROOMOLLOW DRVER, UMM 208'
SAATAAI A CA- 92705
aA1+MANA CSS.
92705
(714)751-9151 CBVf
-4.4.85
USE OF PERMIT
GaMAL f31T17:13M
In L.-, @6 61 H10H C4mm)EN '`dNA114 55 LF. @4- i31t i,` -i
ORCO STANDARD
•.
6 FT. WALL, MAI LbTr
4:F FT. WALL si.00 LF
FSTMATEDCOUTOFCONSTRUMOV.
4M0
PERWIC FEE SUMMARY
CONSTRUCTION 1E.E • 101-000-419.000 �"7�.a�►
t
A ' C •.f
fi OUB, (YrAi. C6AT81 `R1JCU0N �ND P1.;AW C��.r•.G`.f.0
72.c70
I.iti:3`3' PEE -PAD E9=1
".00
IP It PTR
RECEIPT
DATE �g
t� ` W t ✓ r�.'
Bf
f
DATE FINALED
INSPECTOR
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
0. 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
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
7— --6v
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final��
rld
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
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)