0007-172 (MISC)LICENSED CONTRACTOR DECLARATION
| nalty ofperjury. that ! am licensed under provisions oV
with Section 700OofDivision 3of the Business and
`Professionals CocleNnd myL�ononivm�n�moand 000u�
uve�o#~ ' '. uv.o/mm Exp. Date
�
uam
Signature m
i hereby affirm under penalty of perjury t ha t I am exempt from the Contractor's
License Law for the following reason:
( )� |, as owner of the pmparty, or my employees with wages as their
'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 �roperty, am exclusively contracting with licensed
contractors to- construct.,the project (Sec. 7044, Business & Professionals
I am exempt under Sq'Ction 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 I declarations:
have and will maintainla certificate of consent to self -insure for workers'
compensation, as prov,ided for by Section 3700 of the' Labor Cocle, for the
performance = the work for which this permit =issued.
( ) .| have and will maintain workers' compensation insurance, oorequired by
Section 3700 ofthe Labor Code, for the performance of the work for which this �
permit is issued.' Myworkers' compensation insurance carrier u policy no. are:
CaOe STAT9 MD Policy No.
(This section need not be completed if the permit valuation is f6r $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 soals-_to become subject to the
workers' compensation laws of California, and'agree that,ifil should become
subject to the workers' compensation pyovisions of Section 3700 of the Labor
Code, I hall orthwith comply with.,th osq� provisions.
y Applicant
Warning: Failure to secure Workers' Compensation coverage is un, lawful/Ind
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 u pannu subject to the conditions and restrictions set forth on his
application.
.1.Each person upon whose behalf this application ismade & each person au
whose request and for whose benefit work iuperformed under o,pursuant m
any permit issued as result cxthis appncmon agrees to, a vxon, indemnify
ahold harmless the City cvLaOuinta.its officers, agents and employees.
2. Any permit issued as o result o/this application becomes null and void if
work,is not commenced within 180 days from date of iaovanno of such
' pa,mu, or cessation ofwork for 18will subject permit to cancellation.
|mrtify that | have read this application and state that the above information is
| agree to comply with all City,
consti�uction, and hereby'gwthorizg?--re-pr--epentatives of this City to enter upon
the above-mentioned
BUILDING PERMIT
DATE VALUATION LOT OW7472 TRACT
JOB SITE
APN
ADDRESS 48-747 Vl,'VrA PAL OA0.90
OWNER
CONTRACTER DESIGNER EN61NEER
PO BOX P) 6
79-295 RANCHO LA QKIDITA DR
LA,QtMJTA CA 92253
LAQUWTA CA 92253
USE OF PERMIT
UM am I -A M MIS
Egro"TED COW OF comyrRuanow
151100000
SUB -TOTAL COROAMMON AND PLAN CIV
LESS PRE-PAIDF=
$0.00
RECEIPT
DATE
DATE FINALED _rSPECTOR
'�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
i
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Stol
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:
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Thle 24
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