0101-107 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of..perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals 'Cdde, and my License is in full force and effect.
License # Lic. Class Exp.' Date
F �ss� h
Date j 'Signature of Contractor i t �
�,�
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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & ' Professionals ,
Code).
O 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 permit is issued.
\Q )., 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 p 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 -1.'
comply with those provislo�rs.
Date :- ' If rf rj Applicant
Warning: Failure to secure Workers' Compe nation coverage is unlawful and
shall subject an employer to criminal penaltiedand 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.
IMP_ ORTANT _Application is hereby made to the Director of Building and Safety
rfor a permit subject"to tthe 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
rwork is'.not commenced within' 180 days from date 'of issuance of such
permit, or'cessation of work fo`r..180 days will subject permit to cancellation.
1 •certify that I 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/rgpresentatives of this City to, enter upon .
the above-mentioned property'for inspection purposes. a r
Signature (Owner%Agent) Date
BUILDING PERMIT PERM T/!
DATE J{ pp ! t VALUATION LOT 010J,_.10'j TRACT
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JOB SITE
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ADDRESS47^�S
VLA 7,VIRICU
�ENINEER
OWNER
CONTRACTOR DESIGNER/
cCAADY& lVM)6iY
.
CARADAY & liaJAN a
17480 B, 1711-IRV. 0106
17480 & 17TH M", #106
Tue,Vw CA 9211,780
TUSIM CA 92780
(714)508-4440 1_13U, 4.485
USE OF PERMIT
103 Ll%615T AVWA.i;AY35 i,F,1' CO R. 'Y;FlRD ti'ti'.Q..;<,tJ'O.t CD STAN AYM
4 PT. WALL
X917 fAtND COY' 0Y CC?NSTR'd7MIC)N
Py. ki°. U'RIR &UNHAARY
CQNSTRUCT1611. Few , 101-000-4,30-000
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RECEIPT
DATE {/
Y
pAj F NALE
INSPECTOR
/� t
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 Walt Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
� POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings Z!9—b% ��
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Qj ���
Final T 27rj
'PLUMBINROVALS
Underground Pibg. Test
Gas Piping
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit s
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)