0101-105 (BLCK)LICENSED CUNTRACTUN ULULAHAI IUry . -
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch'dpter'9 (commencing. with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.'
License # Lic. Class - Exp. Date
S
i
Date/t ±f l Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason'
( ) 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).
(:) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project -,(Sec. 7044,. Business & Professionals
Code).
() 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
!performance of the work for which this soermit is issued.
t� 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 _ Policy No., '
(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 of California, -and agree that if. I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall fotrthwltcomply with those provisions`'`\
Date: f 1 �?: } it l Applicant d t.
Warning. Failure to secure Workers' ComQp"ensation coverage is unlawful and
shall subject an employer to criminal penaltles-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 -ha ' rmless the City of La.Quinta, its officers, agents and, employees:
2;, Any pemit issued as a result of thisapplication becomes null and void'if
.work is not commenced within 180 days from date of 'issuanceof such
permit,,or cessation of.work for. 18,0 days will subject permit to cancellation.
'.I certify that I have read this applicatioh.a* hd,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 for inspection purposes. `
/ � 6
Signature (Owner/Agent) , r> Date! t 7
J
BUILDING PERMIT PERM T# '
DATE ` 1 y VALUATION LOT !lLE�X^.Y9A� TRACT
i t $5
2,6152
JOB SITE -
APN
-
ADDRESS 6�9 ��q� q�Q s�'•ygyXy�
4 7-84..7 IA G.iI.�,f-66.6�H
� ••.
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CAWADAY A MWANY
CANADAY A COMPANY
NY
,
17480 R 17TRIM #106
3.7480 F. I7TH .71, 010
VAS'M' f":'.i`•L - 9”, 80
`,1'[7ciM4 CA
WMO
14)5034WO I
MIA.448.5
USE OFPERMIT
9.5 f:iF' 6' :i!!�f~ 3'dA•LI.�'d Ian' d° Cwt)�'t;tt�' S!":� �I:PA.I:.D.,/�lrf.5.�'".FtiP3''17:iD
OFT WAIA, LP
4 Irf, yw/.'9LI, 'gni-
.
t _
WrIMA33M COST OF CONSTRUCM014
MA)
CQZ,3,'�7 VIC'3 IONi Y 11 til -00 0,418-000 8.000 04.E
ST3`�p3,`t�'i°�T�, t�t�33 �►��Ia ; GJAi' :4�� A3� C�EiJ��"�
$54:t00
-S DITI" now
VASA)
RECEIPT DATED
T INAL
INSPECTOR
INSPECTION RECORD
OPERATION I DATE ( INSPECTOR
BUILDING APPROVALS
Set Packs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
PLUMBING IAF(PROVALS
Gas Test
Electric Final
Final
Final
Water Piping
POOLS - SPAS
Plumbing Top Out
BLOCKWALL APPROVALS
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
steel
Set Backs
Encapsulation
Electric Bond
Footings
/—�fj�p� �_/.�
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underaround Electric
PLUMBING IAF(PROVALS
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
Final
COMMENTS:
die
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors 4,
Temp. Use of Power
Final
Utility