9812-020 (AR)LICENSEDCONTRACTOR DECLARATION.
Thereby r . , ereby affirm - undepenaltyt , . of.perjury'hat fam licensed'under provisions of
? F Phapter 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 -
711 QM 411,
101310
l
i _44
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under, penalty of perjury,1that .1 am exempt from*the Contractor's
Lice,nse-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 orloffered for
sale (Sec. 7044, Business & Professionals Code).
1,. as owner of. the property,*.am exclusivelycontracting 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 h ereby. affirm under penalty* of perjury one of the following declarations:
O 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.
Iha*veand will maintain workers' compensation insurance, as required by.
Section .3700 of the Labor Code, for the performance of, the work for which
permit is issued. My worker6' 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
rtify th at 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 ' rthw0h qpglpI irovisions.
y W� , ,
Date: -),Aloplicant
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 the cost of compensation,. damages as provided for in Section 3706
pf:the Labor.Code, interest and attorney's fees..
iIMPORTANT Application is hereby made de to the Director of Building and Safety
-for .a •permit subject to the conditions and restrictions, set forth on his
application.
1: Each person4on whose behalf1his application is made & each person at
Who
se !equest.and for whose benefit Work is performed under'or pursuant to
any. permit issued as a result of this appficaton 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
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 I have read this application and state that the above information - is ",
correct..) agree to comply with all City, and State laws.relating to the building
construction,. and, hereby authorize representatives of this City to enter upon
;pec ic�?pu
the above-mentioned property �fo.r'enrsl t. r.
I r pposes.
to
Si nature (Owner/Agent) Date
V
BUILDING PERMIT PERMIT#
"0000000
DATI� VALUATION LOT' TRACT
4015%
JOB I SITE�APN
ADDRESS
04-373-003
OWNER
CONTRACTOR DESIGNER ENGINEER
A 0-%h1r1%,0"NT.TIFb
0)AMUNI[TIES
1533�slo.VIYI ST&UT SITE 0200
1.333 SO. -11) STREE'L'STLA200
SAN i8MI-ARDNO 974
SANYBERNARDINO CA 92408
iii 1-0007 C -8 -LA Mo
USE OFPERMIT
CRANOVDE-1 R84 FLAN',,'M MAN 2XINUMNO C0N&T9.UCsT1Qi4 (ADIM,
OF SAKE PLAN 1'TW,
I'AAC11' CONSTRM110VI c. o o r!
.,e
ESTURIAMM C0*9F 01F
" 7 �q
17 -
CIDN,411.UCTIQN F.F-,'I-: 4014)0 -418 -WO 31.911
PIJ
ru,XIRICAL
s7mul4d mcmoN ii -a -4t. � f) I 01-wo-241 bOO
TXP',RAS11'RV7rVRI3 FiVE 22540)-443-342-
�YT N.MMUCTIONAK TIAMICHS07
WfBjr W., CON D K,
0 9. 5 1
llss Plan -PAID PENES
% XOTA - ft
AIWATFION OU 'NOW'
S209.51
RECEIP
DATE- BY DATE FINALED
INSPECTOR.
,-k
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
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
Fbftures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)