0004-186 (BLCK)' LICENSED CONTRACTOR DECLARATION ,
lereby affirm under penalty of perjury that I am licensed under provisions of
apter:9 (c(immencing with Section 7000) of Division 3 of -the Business and
'Professionals Code, and my License is in full force and effect. '
License # r Lia Class Exp. Date. '
Date �? Signatureof Contraofo'r%! Y
OWNER -BUILDER- DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1,'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 ;
-contract - ors to construct the project (Sec. 7044, Business & Professionals
Code).. 4 ✓ /
O Lam exempt under Section B&P.C. for this reason r
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, t
performance of the work for which this permit is issued.
I 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 STATE FUND Policy No. 129.99 U141TO019334
(This section need not be 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 of7california, and agree that if I should,become
subject to the_work rs' compensationt provisions of,Section 3700,of the Labor
Cpde sh l602rft�h comply with m rse provisions
rate:%�6w. 7 Appllcant�l
Warn g:.- ailure to secure Workers' Compensation coverage is unlawful and
shall subject an employer td criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages'as provided for in Section 3706
of the Labor Code, interest and attorney's fees.'
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the, conditions 'and restrictions set forth on his
application.
1,'Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as`a result of this applicaton agrees to, &:shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within '180 days from date of issuance of such
permit, .or cessation of work for 180 days will subject permit to cancellation.
—1-certify-that-l-have-read this application and state that the above information is.
'correct. I agree to comply with all City, and State laws relating to -the building
construction, and hereby. authorize -representatives of this City to enter upon
tth above-mentioned property for inspection�purposes!
'Signature (Owner/Agent) Date
'-BUILDING PERMIT
DATE ' T VALUATION ' LOT Q4~g TRACT
. I
04117=,-
4lii/
JOB SITE -
JOB
APN
ADDRESS . • 47,741) VIA MONT..100
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CMAT.?AY4 C014"ANY
VJkCAMN POOL43
17480 E 17TH' SST. 0106
9522130A}i4LDSONROAD'
TUSTIN CIA. 92780
I.tTC`�Al'It,'t>�, uxy CA
F,.
9235 to
� 4
{760)24$-6045 CBL6 35
«.
USE OF PERMIT
0 -EM EMMA& I3U]1MIING
. 3
1tL:TAINI'NGWALT,13 I.F. 4' MON.
"^
4 FT. WALL 111
"
ksiviawmD COST OF COIurRf?CT-10M
288.00 Y
j?'mm FEZd'. > fT1Y KA Y
t".t?NSTRUO'1'1t7N l"M 8a000 X15.00
Slm-TOTAL CO3NWRVt;',�'iON PLAN C:RECK
$15.00
LESS PRR—PAID I'M
$010D
T MAli PERMW I1TES DUE NOW
x
`
RECEIPT
DATE
I Bl/� I
DA NA D
INSPECTOR
�.
INSPECTION RECORD
OPERATION I DATE I INSPECTOR 1 OPERATION I DATE I INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
J
Set Backs Underground Ducts r
Forms & Footings Ducts
Slab Grade Return Air
Steel
Combustion Air
Roof -Deck
Exhaust Fans
OX 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
Gas Test
Electric Final
Exterior Lath
Heater Final
Drywall - Int. Lath
Plumbing Final
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
'Final
Utility Notice (Pi
Final
Final
-
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs _
Footings ���
Electric Bond
Main Drain
Bond Beam s � enj
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
Encaosulation
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
'Final
Utility Notice (Pi