9710-101 (BLCK)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
59 061 B
Date - 1,010,4119 Signature of,Contractor
OWNER-BUILPtR DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, 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).
1, as owner of the property, am exclusively contracting With licensed -
contractors to construct the project (Sec. 7044; Business & Professionals
Code).
O I am exempt under Section B&P.C. for this reason
Date
ate 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 3706 of the Labor Code, ' for. the
performance of the work for which this permit is issued.
I(% I have and will maintain workers' compensation insurance, as required. by
Sedtn 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.
-UNICA . Ki INS CO BASO -119 -14179
(This section need not be completed if the permit valuation is for '$1 00,00. 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 P
%fit I should become
subject to the workers' compensationpro.. i to Sf f Section 3700 oJth6'Labor
Code, I shall -to Mith comply with tho ro sio S.
Oate: ?Applicant
Warning: Failure to secure Work&s' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to'.$1 00,00, 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; 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 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-mentioned property for/ins b
V
Signature (Owner/Agent) D . ate
PERMIT # 'CONTROL#
BUILDING PERMIT 9711110-1.01
DATE VALUATION LOT' TRACT
S2,%4.7.5 6141
JOB SITE I APN
ADDRESS 79-,%.5V1A FLORENCE
OWNER CONTRACTOR/DESIGNER/ENGINEER
U&JADAY&COMPANY CAINADAY& COMPANY
1.570 BROOKKOLLOW DRIVE, SUnE 208 1570 BROOKHOLLOW DRrVE, SWE 208
SANTA, ANA CA 132705 SANTA ANA CA 92705
(714)751-9151 CBL# 4495
USE OF PERMIT
SUILDING
5FT. WALL 95.00 ;LF
4 FT, WALL 28.00 LF
ESTINtkTED COST OF CONSTRUCHON'
PERMIT FEE SUMIAIARY
CONSTR(Y-MOK FFX,, jol-000.418-000
CONM'VCT[ON 1UND PLAN C14t-C1:.
L '8S PH "SE'
;ri -PAW VL
OCT 24 7997
'TOTAI, PERMIT FEES DUE NOW
RECEIPT I DATE BY? r DATE FI NALED I INSPECTOR
$51110
$0.00. -
$54.00
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE TINSPECTOR
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
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: