9704-026 (SFD)-LICENSED. CONTRACTOR DECLARATION
co i penal h Ili�ensE;d:u:nde�, -,g �f
-,I:hpreby affirm uncle ty�'o perjury. t at 'am I prb� - i§io'ns
Chapter c mencirig with Section 7000)'04 Di'visi:on'3'of*th;e,ousiness.and
C\J c) !;:-`0r6fe§sior�als Code, and my License'- is in"Jull force and'effect, -
LJJ
0
tCV) Licehse.#'lc
- SS Exp:, Date
`
LO
W,
' Contractor Z r-, ate Signature Of
DECLARATION
0ECLAR
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W UJ' I hereby affirm undpi penalty, of Oerjury that-11-am'exempt from the Cont , ractor! , s
•
License Law for the following reason:
.'Z 1, as owner of the propeWrtyorks , or my:pmployees W6 wages as: their. , ' sole
compensation, will do the _ property,
the structure isnot intended'. or'off eredJor
sale (Sec. 7044, Busines's & Professionals Code).
1, as owner, of th6 pr6p6q, am e*xclusivelyl'cohtracting with, licensed
contractors to co, project
'(Sec. the 6roieC '(Seq. 7044,. Busines's., & 'Pr'ofe'sSion'als
Code):
I am exempt under Section '! B&P.C. for this reason
LO
Date
6 Signature of qwner
Cq
<
WORKER'S COMPENSATION DECLARATION'
2.Z I hereby.affirm under Pen . ilty. ., ofe uryone o
..p .11 rj' f . 4he: followir�g'. declar"declarations:.
Lo,< Cr
0 1 have and will maintain a 6ertifjdat6 of consent to self-irfsure.for Workers"
X LIL compensation, . as provided for, by Section. 3700 of the Labor Code � for the
r-:
0'W�-—
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perf&rmance of the work for which this permit,is issued..
A lhave and Will maintain workers' compensation insurance, as.r6quired�by
section 3700 of'the Labor Code,'for the performance of thework for which this
CL
yworkersF_;'; permit is isspied.W com pensation insurance carrier'& policy no' are:
Z
Carrier Policy NO.
P Icy
2,131411, -TW
< (This section need not be completed if the Permit valuation'. is for $100.00 or less).
O I certify that in t work f It is
the performance of.the wo 6 which tl�iis perm' issued,
pe
I Shall. not emoloy,any person in any manner so as to become subject to the
workers'' compensation laws of -.California, and agree .that if r should become
subject to the workers' compensation'or6visions,df,,"S'ection',3700-of. the Labor -
ode, I sh 11 forthwith comply, with those. OrbVGions
Dater
pplicant
Warning: Failure to secure Workers' Co m -pe ��ii& 6o4_
rlisafil( rage is unlawful and
shall sub o criminal penaltiesand'civil-fines up' to $1106-000;�in
subject an employerto
'he
addition'to't cost of compqnsatio6, d6hages: 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-Sbifety
f a t o e conditions arfd,' restrictions; set -forth on his
or 'permit subject th
application..
1. Each person upon, whose behalf this application is made & each person at
Whose -request and forwhose'66nef it work is performed under or purs6664JO
. w4jz any permit.issued as a result.of this a . pplicat6n agre es to & sh all,' indemnify
& hold harmless the CityofLa-Quinta,-its officers, agentsand employees.
2. Any permit issued as a result of.this application becomes null and Void if
Work is not Corilmenced-withih! 180 days- from 'date of issuance of -such
permit, or cessation'df w6rkJoir' 180 days Will subject permit to cancellation.
. . . ' : '. .'*'in f
I certify that'I have'read this application and btate'thai the, above ormation-!'s
• correct. I agree'to Comply With all; City, and State_ laws. relating to,the .building*
'construction, and hereby authorize representative "ofthis City to enteruPon'
the above-mentioned property for inspection -purposes
.
J"
nnaturei (Owner/Agent) D
-PERMIT# ''CONTROL
BUILDING PERMIT..
54
VALUATION— --LOT 191 Tfl CT", g
PATE 14)9 `SO A
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'j40DBD_w-()UuV-ak1VL
ADDRESS %V r
APN
'OWNER-
CONTRACTOR/DESIGNER/ENGINEER
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C1NJ11JR)V' CROM011. W. Ut ITS`
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'C'ENT 33'C"'O' Ut XJ1 N 1`11ES'
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(90?)381 (�Duhll 21-j
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USE OF PERMIT
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1801, -V AL 9 OR "M 104..
Ua_kfi Y, PI; A�'N_Wk� ki.A14 C.Plklk FFR -N REIKKICED Fly.13010fF(A
INP
M, ACT Ci ba 11,445,00 SIF
I"T
qT S� -RUCTION
1'nlL4"-c I.,* nie,
011 il 10 .'07'10-0 )00
I Nil F14r,i(1 ttQC1-!lji� 000
Y,
46,1 M042,1- .CIO
f Nmk, A Si,.I li x 0,(B Y i'l, C w01-4113-342' '12JO-45.46
T V1,10 4,AND P'LAN CRECK
$V.B-TO AL CC)Nf;'Tg U
$31
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Y(Al"TERM I'll -FIEF.S TY(fril,
Tf 11MV
6.5
$3,10 0
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RECEIPT�_
DATE ..
BY/ 7
*
INSPECTOR
7.
4
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
-4-9-2
Compressor
Insulation
7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
3
Final
Final
POOLS - SPAS
BLOCKWALL
APPROV LS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPRVALS
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
k117 J tiv
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)