0101-106 (BLCK)LICENSED CONTRACTOR DECLARATION �.
,f-Cn N/ + kt l hereby affirm under penalty of'perjury that I am licensed under provisions of .
4 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
c14W� Professionals Code and my License is.in full force and effect.
• M" License # S - Lfiic. Class Exp. Date
Z t-- .Date. "' ! f s;f �?r Signature of Contractor ' .
CID 0
iyY V ; .�� r'
-0W 1 N.ER-BUILDER DECLARATION
W .W I. hereby affirm under penalty of perjury that,l am exempt from the Contractor's.
: License Law for the following reason:
;,Z ( ) 1, as owner of the .property, or my.employees with wages as their sole
tcompensation, will do the work; and the structure isnot intended or off ered•for
' Z sale (Sec. 7044, Business & Professionals Code)., '
t .., �'(,; •) I, ,as 'owner of the property, am exclusively• contracting with licensed
"contractors to construct the project (Sec. 7044, Business & Professionals
Code):
" M n,O 'I am exempt under Section - B&P.C. for this,reason
N y. Date ' Signature of• Owner
.:0:
U Q WORKER'S COMPENSATION DECLARATION
�,;Q Ii,hereby affirm under'.penalty of penury one of the following'declarations:
r H O O c 1 -have and will maintain a certificate of consent to self -insure for workers'
X W W ,•compensation, as' provided for by `Section .3700 of the Labor Code"*,for,the
01-i4performance of the work for which this permit issued.
m Q U �(y I have'and will maintain workers' compensation insurance, as requirecIty
♦ e.
`0 •C) ' Se, n'3700 -of the Labor Code, ,for the performance of the -work for which'this
ii o ,� 4 . permit; is issued.:'My,workers' compensation insurance carrier & policy no are:
r ' Z Carrier,' Policy -0.
CO
(This section need not be completed If the. permit valuation'is for $100.00 or. less).
I, certify that in the performance of th6work for which this permitis issued,
' "• ; I shall not emplby any person in any manner'so as to become subjecf,to.the
Rn/l �r
r workers' compensation laws of"California, and agree that if I should become
+1 w subject to the workers compensation provisions of"Section. 3700 of the Labor
Code; I shall fort w+th comply with those prov sions. '
w.,
Date:' ``•• (jAppllcanY uy/
Warning Failure Ito 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, - dam mIage.s as provided for in Section'3706
F . of,the 'Labor Code,.interest and. attorney's fees a , '
3..
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'pers6nupon w' hose 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 '
r:. & hold harmless the City of,L'a Quinta,'its officers, agents and employees.
-2. Any perm1tL issued as a result of thls.applicaton becomes null and void' if'
work is .not commenced within 16 -da' ys'.from date of issuanceof 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 tagree to comply with all'City, 'and State laws relating to the building
r , construction, and hereby authorize representatives of this City to, enter upon
the.above-mentioned property;for inspection purposes . '!:
s Signature (Owner/Agent) Date t of
BUILDING PERMIT. PERMIT#
DATE VALUATION LOT' f���..�y, TRACT
4�
=MAX ._ : .� ��
26152
JOB SITE `
APN
F
ADDRESS
41-8705 VIA, 2117RCH
OWNER
CONTRACTOR/DESIGNER/EN INEER
,
CARADAT C'M&PPalY .
C,ANADAY cit: Wit:+MPAII
.
1-7480E.
CA 92760
IragrIN 92?80
(714).,508.44,.4
03,1141-44&.'.
'
USE OF PERMIT
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6 F '. 'SOU,
90.09 R.IIWALL
19.0.4, LF
As?�. I,k319—AA C,O (W �:C1 S"la' O #q I
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CONSTRUCTION M 101 o.000-418: 000
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MIS PRS-PATI)FM
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���.d�+ .
RECEIPT
DATE/ } (3 s
l
BY'
D
FN L D
INSPECTOR
I // V)p
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Bond Beam
/�Zy O� �dL
Z_�=o
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Final/��_rf�'
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:
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