9810-040 (BLCK)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT
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 DATE VALUATION rA i,:$f►.s.f113 LOT
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp: Date
JOB 39.1561 13 i �i_'siii ADD Ess 47-6811 VIA fg0.'N iG0
D/ate �� • i nature of Contractor' r// t �t �\ OWNER
OWNER -BUILDER DECLARATION CXN'AD� AvA 6a. ` N t N i
1570 rROCiiI:1401:10W DRIVE, hereby affirm under penalty of perjury that I am exempt from the Contractor's `�, SUTIii 208
License Law for the following reason: SANTA ANA CA 92705
( ) 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). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting' with licensed' U"G i Ng ,
''
contractors to construct the project (Sec. 7044, Business & Professionals ���
Code). 109UZ 61.4 401Y 4' GAMEt+T:l3LOCK WALL
( ) 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
perfotmance of the work for which this permit is issued.
�( )i I have and will maintain workers' compensation insurance, as required by
Setction 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. 1197-14 . 179
M11WARX3, INS C'0 -
(This section need not 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,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
Vde
ct to the workeres' compensation provisions of Section 3700 of the Labor
, I shall fortwith,comply with those pro .�
Date: P�!) Applicant
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.
4' ,t. WALL
PERMIT # CONTROL #
�)�3)If~414fl
247 TRACT '8374
APN EeTJ-1 Pd�-Q6.P.f
CONTRACTOR / DESIGNER / ENGINEER
"'fy'"3ArJAY a4'. 'COMPAN-Y
1670 BROOK;KOLLOW DrdV , SiJCUE 208
5Alv`l: ANA CA 92705
(714)75t-91,53 CALF 4485
10.00 .L
40.00 LF
'VtMUTE 1) CY.WFOr, CONINTRUCTdN
M1E.CARL VT, SUMMV
f t,:ili:S•TiL4 c—rt.(.)N k d0i-Ot!()=411,5-tlOtJ �b3. +
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, indemnity
& 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 prope>1or 'spe6tion rpurpose c
RECEIPT
'Signature (Owner/Agent)
f
St 13-'iE'7 ALS CONS"TUIC 'ION AND P9. AN CH C,
LESS P.t L -PAM dECS
}
DATE BY DATE FINALED JINSPECTOR
$0.00
$0.00
S6 3MO
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
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 / / A >t
Main Drain
Bond Beam /
Approval to Cover
Equipment Location
Underground Electric
/
Final _� t / _
Underground Plbg, Test
Gas Piping
PLUMBING APPkOVALS
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.J.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: