0002-035 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby,affirm under penalty of perjury that I am licensed under provisions of
Chapter 0 (commencing with Section 7000) of Division 3 of the Business and
• Pf6fessionals Code, and my License is in -full force and effect.
License4 Lic. Class Exp.. Date
614074 01113 i
Date 1 44* Signature of_Contractcr_
OWNER -BUILDER DECLARATION
I hereby affiim under, penalty. of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, as owner of the propeft or my employees w - ith wages as their sole
compensation, will do the work'and the structure is not intended or offered for
sale (Sec. 7044, Business & Professio4s Code).
(- -) 1, as �owner 61,the -property,. am exclusively contracting with licensed
contractors to 'co hstr LIc-i the project (Sec.' 7044, Business & Professionals
Code).
I am. exempt Aer'Section B&P.C' for.,this reason
Date Signature of,owner
WORKER'&COMPENSATION DECLARATION
I hereby affirm ,under penalty 'of `perjury one of the following declarations:
rations:
I have and will maintain a cert ' ificate.of co6iht to self -insure for workers'
compqnsation,%as provided, or I by Sectioii 3700 of the Labor bode, for.the
performance of the work- for which this permit is issued:,
I have - and'will maintain workers' compensation pensation ins . urance,. as required by
Section 000Y6PtKVL8Bor C6de,'forjhe perf6irma-ince of this
permit is issued: My workers' compensation insurance carrier & policy no. are:
Carrier Policy 'No. ,
.(This section need n6t'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
shall not employ any person in any manner do as to become subject to the
workers' compensation laws of CAlifornia,and-agme that if I should become
subject to theY workers' compensation-provisioni of '§ection 3700 of the Labor
Code, I s�1,1',fortk."ith comply with,thd*�e provisions.'
Date: Apolica,nt
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 provider] 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'6ehalf thig'application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
s7
any permit issued as result of this applicator pliciaton' agrees to, '& shall, -indemnify
& hold harmless the City, of La Q6inta, 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,sLich
permit, or cessation of work for 180 days will subject permit to cancell , ation.
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 hereb `y,autkcrize "representatives of this City to enter upon
the above- mentioned,p rope rty Jor inspection rposes
'Signature (Owner/Agent) E....... .....
Date
BUILDING PERMIT`- PERMIT#002_935
"NiA1,30 LOT TRACT
DATE VALUATION --Z)306
4;.
JOB SITE
ADDRESS 43-707 ViSTA PALGNIMNO 1
NAMPr: r
T
APN
645-160-006
c7
OWNER
CONTRACTOR/DESIGNER/ENGINEER
gi 6
BOX i 716%
79-295 VtNCHO LA QUNTIA DR.
LAQ01NTA CA.' 42$3
!JQU [NI"A r CA 02253
CSIA 2496
USE OF PERMIT
`SI 01.rV F f U, 1 Y DW173 L L 1 N1 Q
SM -LOT 55 PLAN KA -Ra - PET DOESNOT NCYLLVE BLOCK -WALL OR(,
POOL 731,1,s Pj_nN CH8CX;KVX REDUCI-ION FOA 1S9Uk%1C_6 OF
=T011001143a. MON'
710,00 SY.,
INITIMAXEM C7081* Or! COINS RUCTIONT'
PJ m1hiff'r, Or, sum-AIARV
C-ONSTR DON Af:k: lot -000-41131000
10 1 _0A0_,A
A 33123440NMAL TIM A V vo "o
ELEUNUCAL i7UE I O.t -0Q.0A20000
PE i1MF3:CidCr!
'ROW' 0
i M 0 T f C Wl'!`Rt RF,54D i n - W $35.i4
VIRZADNO!" . 10.1.0 0-421000
IMS
W ovulky,_UIL NTIACT kv
Ai(T IN ,IC PLACES R-14*31V $628,417
SUBM AG CON'$ 11MN AINTY. t4HECK
5TRUC PLAN -I' K.
9.05
$%fA
'SOX -0
TQTALPERMIT FEES AME,"NOW
ss...00-9.0s
[RECEIPT •
DATEINSPECTOR
DATE FINALED
7
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
r
Underground Ducts
Forms & Footings
Ducts
Slab Grade
—pv
Return Air
Steel
Combustion Air
Roof Deck
ID_
Exhaust Fans
O.K. to Wrap
, / –
F.A.U.
Framing
Z 5--p
Compressor
Insulation
,Z8 Oa
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
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I 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
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)