0103-075 (BLCK)! t j • LICENSED CONTRACTOR DECLARATION
h� I hereby affirm under penalty of perjury that I am licensed under provisions of
:�.
F—Chapter 9` (commencing with Section 7000) of Division 3 of the Business and .
Cn, F rofessionals.Code, and, my License is in full force and effect.
License # Lic. Class Exp. Date
r, LLJ
Z DateV �' r 1 �' ' i Signature of Contractor
(D 0. ,
J U OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from,the Contractor's
~ .a, License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with'wages as their sole
compensation, will do the work, and the structure isnot intended or offered for
gFIA (Ser. 7n44; Ru5iness & Professionals Code),
„ (.) I; as owner of the. property, am exclusively contracting with licensed
contractors to construct. the project (Sec. 7044, Business & Professionals
Code).
` C6 () I am exempt under Section B&P.C. for this reason
LO
N Date Signature' of Owner.
WORKER'S COMPENSATION DECLARATION
p2 ZIM I hereby affirm under penalty of perjury one of the following declarations:
U-) <-
0 O 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, -as'provided for by Section 3700 of the. Labor Code, for the
OQ performance of.the work for which this permit is issued. ». 1
m: Q,• U (,) I have and will maintain workers' compensation insurance, as required by
YSection 3700 of the Labor Code,,for.the performance of the work for,which this
1 . LOH permit is issued. My workers' compensation insurance carrier. & policy no. are:
z Carrier ' Policy No.
O
J- . (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
subject to the workers' compensation provisions ob,sectlon':3700 of•the Labor
3 Code, I ihall forthwith comply with those pr-ovlslons�)
Dater "s i�'7.•>rs�tjF Applicant�.C..'_
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 thecost 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.Directorof 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,Cuinta, 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'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
the•above-mentioned property fcr hspe)cn purposes.
Signature (Owner/Agent) ` ^ '"fit " ' Date--,
BUILDING PERMIT FERNY# r
DATE VALUATION•h . LOT 0103A)IS TRACT, '
26152
JOB SITE
ADDRESS
APN
•
OWNER -
CONTRACTOR/DESIGNER/EN (NEER
1.7480 IL IT.H ST.1-2 oaf '
17480 R- 17TH V, 0106
1"f� 1x3 CA, 97780
`.ful:= CA. 92780
(714)508 4440 MIX 4485 - . ,...
USE OF PERMIT
Ole 6' fit''SWCR: Mr.A.LL 4l J,, F. C"�3r4' H OCK WA,1L1-
�l,RD, .. � ,
ORCO STANDARD,.
4 Fif.1rri°A LII 41.00 LP
M Or
CON1'TRl7O'TION VERS 101.000.418-100 $54,00
y
b
R
�x ou 8-1,1'y1A1.CON9JI f ONANDPLAIT MM
�$a�0t
Liy)ARE-PAID i±•.q
,.0fJU�/f
.
'IDTAX ym= Yns XY(YE "low
�lf3
RECEIPT
DATE f
BY
Dp,T F ALE
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
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 BacksElectric
Footings y:::
Bond Beam
Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
�/
Final �� l �'
PLUMBING APPROVALS
Underground Pibg. Test
Gas Piping
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:
-