9903-026 (SOTB)O
d z WORKER'S COMPENSATION DECLARATION
C:) Q,,� I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate -of consent to self-insurel for workers'.
X Uj = compensation, as provided for by Section 3700 of the Labor Code, for the
Q, _ Q performance of the work for which this permit is issued.
m,Q U O I have and will maintain workers' compensation insurance, as required by
•Q. U Q Section 3700 of the Labor Code, for the performance of the work for -which this _
Il rn„ H permit is issued. My workers' compensation insurance carrier • & policy no. are:
2,500.00 LS
Z
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of that"I am licensed underprovisioris of: •
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PERMIT#
°tet BUILDING PERMIT
NT.IftSI TED W 4' cif;, C ININIM � I t :
perjury
(This section need not be completed if the permit valuation is for $100.00 or less)..
yrR g oz "Sum m" '
H
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
" Prkessionals full force
DATE' VALUATION LOT 1 TRACT
a�?U 4 i1
W`
Code, and.my License is in and effect. - . _ _
Class '
.�(�15%
t
workers"compensation laws of California, a d.a ee hat i I shot Id become
r qq r
subject to the workers' compensation provisions S�cti f� 700 of the Labor
Code, I sVl ibq IO6mply with those provlsio s.
C)
Li ense•# µ Lic. Exp. at -
JOB SITE t
APN.
111rAate�,
15u1 CS / 3,' 1
ADDRESS 47-715VA�Ai10N,ri
64.fa••1ir�e••033
.,
OWNER
CONTRACTOR /DESIGNER /ENGINEER
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Signature of Contracto
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� Fr C:)
OWNER -BUIL DER,DECLARATION
i:`'1.�V�' DAY & COMPANY
C Nz1DAY & CONTPAINI Y•
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
157013.13.iaQ1�+.�-�C3�.i:�iW Ta.lZtVE, �Urill 208
i. �7G f3i�Cit�i:IliJlai.Li41� i�R]V,�, SiiITi k,0
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License Law for the following reason: F
SA.NTA.ANA t..,'A 02705
SAN't•A AICA CA 92705
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( ) I, as owner of the property, or my employees with wages as their sole
C13LA 4485
compensation, will do the work, and.the structure is not intended or offered for
USE OF PERMIT
-- - .—
—sale.(Sec._7-044,_Business_& Prof essionals,Code ).
( ) I, as "owner of the property, .am exclusively contracting with licensed
UI
-BLD
ING
"
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
CONSTRUC �' BOA1"DOCK .MM +'1'A S:PER PLAN
LO
NDate
Signature' of Owner
O
d z WORKER'S COMPENSATION DECLARATION
C:) Q,,� I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate -of consent to self-insurel for workers'.
X Uj = compensation, as provided for by Section 3700 of the Labor Code, for the
Q, _ Q performance of the work for which this permit is issued.
m,Q U O I have and will maintain workers' compensation insurance, as required by
•Q. U Q Section 3700 of the Labor Code, for the performance of the work for -which this _
Il rn„ H permit is issued. My workers' compensation insurance carrier • & policy no. are:
2,500.00 LS
Z
Carrier - Policy No. ; .
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UNIC,P:.3 %s .5050 t.3 � 119F
NT.IftSI TED W 4' cif;, C ININIM � I t :
41 Q
(This section need not be completed if the permit valuation is for $100.00 or less)..
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J
O . I certify that in the performance of the work for which this permit is issued,
PLAN C, 1 t''•K;"Fi"4s { $35..10
I shall not employ any person in any manner so as to become sub-ect to'thef
,y -1 t 7� t Cpl )Oj (1 �t8.t)Op 154. }0
workers"compensation laws of California, a d.a ee hat i I shot Id become
r qq r
subject to the workers' compensation provisions S�cti f� 700 of the Labor
Code, I sVl ibq IO6mply with those provlsio s.
„ , �_ , .
s, tFczrfcclzt� �j taa�; , t}u-. ��, oft ..sc
d'`
pplicant
m 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 �y
addition to. the cost of compensation; damages as provided for in Section 3706 1 ,
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
v.
application., .
`ec
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(T3-'IYiTC>-T.f:QtS"1:4�t:t3.3C4Ai'AIIS,baI,A.N C'ITCIC
& hold harmless the City of La Quinta, its officers, agents and employees. )I ;GESS 1?jr -PAID ,PEES
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 aon* }39Ai, PERYWI AT`C DUE NOW
cancelltiJAN.Q'l99Ji1
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 laps/ rM�eating to the building , !
construction, and hereby authorize rep�e�gntatives4oi�his Cit oto'enter upon .� �{;`.
the above-mentioned property forpectio pLdrpos i
Q RECEIPT DATE BY/
'r ' . �Slgnature (Owner/Agent) ' �/� Date
a
�k
DATE FINALED
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�Cp.aiJ
$89_60
CTOR
L INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
Coll 1011,
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
BLOCKWAL PPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: