0002-036 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty. of perjury that l 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 Data
W B 03 1120
Date f Signature of.Contractor
( 1-
Al
O.WNER-BUILDER DECLARATION.
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law foF the following reason:'
{ ) I,- 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). ,
( ) I, as owner "of• the property,: am exclusively contracting with licensed
contractors toconstructthe project (Sec. 70441 JBusiness & Professionals
Code). `. .. .
O I am exempt under Section' B&PC. f60his reason
Date ' Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm. under penalty ofrperjury 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.
( ) •1 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:
Carrier Policy No. Y
ST. tbti0,0007338
(This section need 'notbe`completed if the permit valuation is for $100.00 or less):
O 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 hat if I should become
subject to t e porkers"compensati'?g,provisions of Sedt'iorr 3700 of the Labor.
Code, �l hall forth , ith comply with those'prowsions:
Date: /�•/ �f Applicant 'f•
Warning: Failure to secure Workers" -Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation; damages as provided for in Section 3706
of the Labor Code,`interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject, to• the, conditions and' restrictions set forth" on* his
application. t ,,
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
&hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of,this application becomes null and void if
work is not commenced within. 180 days from date of issuance of such
permit, or cessation of work for 18Qdayswill subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with'al1 City�and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection poses:
Si nature (Owner/A ent) > ��•-`" `"' Datellr�
`BUILDING PERMIT PERMIT#9����.
�.5:
,n
DATE VALUATION ,�c s-0,91..20 LOT,., qb TRACT 9317i5 ,.JOB
t
SITE'
ADDRESS 727ViSTA 3' �L�IU�Dl4`!i�`` o �'
APN �1%^'itY� l�l`�{►
t'
OWNER
CONTRACTOR /DESIGNER /ENGINFFR
•r- Q�'^r' ver e{r°'P /�A t7 At t'
.ori n n ff a �e �r�I�,ar
i, . u\Ah.0 V 'Too
1 t:1 SOX 1716
IfIvUta Y
-79-295 RANCHO LA Q) JX1�e`IA I R.
LPAQUIi�TA - CA 92253
T.r�.t,UIN'�A CA '92253
'
{760)771.-144E Cf;ILY 12996 '
USE OFPERMIT
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C-'ON,4 TRILICTiON lr� 101• *-4913-000 1.20.3.00
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LAN G� `�,'� �r . t 01-(1Qf14�!1�,3'1$ $247.07
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13LfJM iTNf :I t 101 -CW -41!9-0(111 $18100 .
$1T?C'NG tv OTION !?Hf,, - I R$0 "101-.:i)f)(1`'2�' -Oil
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RECEIPT(
DATE
Bj
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
.01001
Roof Deck
Exhaust Fans
O.K to Wrap —�—�
F.A.U.
Framing
Compressor
_
Insulation 1(p—
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 9PPROVALS
POOLS
Steel
SPAS
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 ...L
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _ _
Sewer Connection
Pool Cover
Encapsulation
Gas Piping G
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 149,
Temp. Use of Power
Final — ZZ
Utility Notice (Perm)
COMMENTS: