0101-101 (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 Code, and my License is in full force and effect.
License # Lic. Class Exp. Date,.
Date _2 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:
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 &I Professionals Code).
1, as owner of the property, am exclusively contracting with lic6ns6d
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'
Compensationj as. provided for by Section 3700 of the Labor Code, for the
performan ce of the work for which this permit is issued.
Itionhave and will maintain workers' compensation insurance, as. required by
Se n 3700' of the Labor Code, for -the performance of the work'for which this
permfWs issued. My workers" Compensation insuranc6'carr'i4. & policy no. are:
Carrier 'Policy No.:
(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 manne . r.so as'to become subject to the
Workers' -compensation laws of California, and agree that if 11 should become
subject, to the workers' Compensation provisions 6f -S' ction 3700 of the Labor
Code,. 4. F- ow , . '. . , , ,
ode, I shallA with comply with'those pIrovisi sl:,
Date: TYP—D Applicant—
M.,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
Shall subject anemployerto 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 sued as a result of this applicaton agrees to, & shall, indemnify
& hold, harmless the City of La.Quinta, its officers, agents and empl4ees.
2. Any permit ' issued as a'result of this application becomes null and void if
work is not commenced wit ' hin• 180.'days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to'cancellation.
I certify that
at I have read this application and state that the above information is,
correct.
ect. I . agree to comply with all City, and State laws relatingito the building
construction, and . hereby authorize representatives of this City to enter upon
the above-mentioned property for inspec on purposes.:
Signature (Owner/Agent) Date
U
BUILDING
PERMIT 'PERMIT#
DATE VALUATION
LOT TRACT,
fly, J it r
S.I.MS-110 .81
26152
JOB SITE
APN
AODRESS
7.910 V TA. Z V W. UF, t
OWNER
CONTRACTOR/DESIGNER/EN (NEER
MNIADISIX COMPANY
CIANADAY & COMPANY
17480E. ITIT.1 ST. 0106
17480 F, 17171 Ur. 0306
MOT
CA '92780
IMUIN CA
92760
Cl 14").508-4440 C"
4485
USE OF PERMIT
173 'L 6'S1DXPV9.A1AJ35 V-0GOURT YAJU) 11YAWORCO STA. ADAR0
U' "= COST OF W)WIRUMON
4,0WAX)
PKAACTFER 91(f MMARV
CONSTAU+"ION Me
103-000-4,18-000* $72,09
=S-TMAJ� CORMRITMIC AIM PLA14 CMCK
2, 00
1X00 PJUK-PAW) PRE1.5"
$0.00
'JR APIFFESDENO
$72.00
P
[RECEIPT
DATE./
Bj
I DMF
L D
j
INSPECTOR
W
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
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
%2C �� ,�'
Main Drain
Approval to Cover
Bond Beam
2��_p %
Equipment Location
Final
,? ��
Underground Electric
Underground Plbg. Test
Gas Piping
PLUMBING ��'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
Appliances
-
Final
COMMENTS:
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)