0101-007 (BLCK)"LICENSED CONTRACTOR DECLARATION.
I hereby. affirm under penalty of perjury that I am lic;,nied under provisions of
C , hapter 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,
441265 Ca i;
Date Signature of ContracW'
`OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury'that'l am exempt from the Contr'actor's
License Law for the following reason:
1, as owner of the property, or my employees with wages as their sole
compensation, will clothe Work,'and the structure is not intended or offered for
sale (Sec.. 7044, BusinessA Professionals Code).
1, as, owner of the. peope'rty, am, exclusively contracting with licen;ed
contractors to construct the project (Sec. 704 , 4_ 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 is issued.
I have and will maintain workers' compensation -insurance,-as required by
Section 3700 of the Labor I Code, for,the performance of the work for which this
permit is issued: My workets' compensation ;Insurance carrier & policy no. are:
Carrier. Policy No.
CA L YK FAVA I T V GA 70 1 D
(This section need not be;, -completed if the -permit valuation ig for $100.00 or less).
I certify that in the'performaincb. of th6 Work for which this permit is issued,
shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if .l should become
subject to the workers' compensation provisions 'of Section 3700 of the Labor
Code, I shall forthwith comply with those 'provisions.
Date: Applicant' Lot.
Warning: Failure to'secure Workers' Compensation coverage is unlawful.and
Shall subject an employerto 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 t , his 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 Quints, its officers,, agents. and employees.
2. Any permit issued as a result ofthis'application becomes null and void if
work is 'not commenced within 186 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 application and state that the above information Is
correct. I agree to. comply with all City, and State laws relating to the building
bonstructlon, and herebyauthorize representatives of this City to enter.upon
the above-mentioned property for Inspection purposes,
Signature (Owner/Agent) A Date_�-
BUILDING PERMIT PERMIT#
DATE VALUATION COT
TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENhINEER
7o
-s
6 815 5 C ON CEF CION R OAD
CA11MD1W, CITY CA 92234
'D '2441
(�60)3.27-4849 C. L0
USE OF PERMIT
OMI MM All Xf 770,1�17wry
.}ARD
4
WOO LF,
w7, JaNKM con or comnivarlon.
VNIKUH, PER 610AWARY,
CONOTRUCTION ITS 101 -o00-4]'8-00u
-N.
ri -
vr LA kluml.
-olTY
AIM PLAN CI-MCK
ws,.001'
LIE'. 0 Prly,-PAM) IM
WYAL MUM XWO .5. DUE NOW
RECEIPT'
DAT
D
.
I .
I 7r�":%Ai
TTMEY 6 /
[INSPECTOR
INSPECTION RECORD
j OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts .
Forms & Footings
Ducts
Slab Grade
Return Air
Steel i
Combustion Air
j Roof Deck
Exhaust Fans
J{ O.K. to Wrap
F.A.U.
Framing
Compressor
i Insulation
Vents
! Fireplace P.L.
Grills
Flreplace.T.O,
t=ans & Controls
Party Wail 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 rl�T9�'�$' `
Approval to Cover
'Equipment Location
Underground Electric
Underground Pibg. Test
Final
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.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: