0002-116 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions.bf,
Chapter 9 (commencing with Section 7000) of Division 3'of the Business and
Professi6nals Code, and my License is in full force and effect.
ro License #Lic. Cla'is xp' -9 to s
LO 4,407,4 B 7/31/200
I'_ Date Signature of Contractor,
OWNER -BUILDER DECLARATION
I h6reby affirm under penalty of perjury that I am exempt frorn'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 thd structure is not intended or offered ,for
sale (Sec. 7044",' Business & Professionals Code).
1, as owner of the Oibperty, am , exclusively contracting'with licensed
contractors to construct the pro.ject,,(Sec. 7044, Business &,,Professionals
Code).-.
Y)
( ), I am exempt under Section _B&P.C. for this reason
Date
Signature of Owner
WORKER'S COMPENSATION DECLARATION
7
I 66eby.affirm under penalty of perjury ow,6f.the following declarations:
D , O I have and will maintain a certificate of consent to self -insure for workers'
compensation, as'provide'd ioe'by' Sectiion 3706 'of the Labor Code, for the
_J
performance of the work for whi6h this permit is issued.
D O 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 worker s' cornpensafion insurance carrier I & policy no.,are:
Carrier Policy No;..,;.'
D Srpag g1W6
(This P section need not be completed if the permit,.vdluation.is for $100.00 or less).
O 1.6ertify that in the performance.,9f1he Work for which this permit..is,issiJed,
I shall not employ any person inany. manner so as t .o b6come. subject to the
-Workers' compensation laws of Ca!!�pkrand agree that if I should become
subject to th6,workers' c6mpensation provisio . ns of Section 37MGH e Labor
/ Of
Code 'I shall forthwith comply with those l5rovisL!.
Date:' Appl'ican/t
Warning: Failure* to secure, Mrikers' Com pensati6n, coverage is ui(lawful and,
shall'sUbject,an employer to criminal'penalties and civil fines up to $1.00000, in
addition to the cost of'compensation,-damages'asprovided for in Secti66_3706
of the Labor'Code, interest and itto'
mey's tees.
IMPORTANT Application is hereby made -to the Director of Building and Safety
-for a,., ermit 'subject to the 'conditions and, restrictions Iset forth o'n his
application..-
A. Each person" upon whose behalf is made .&*'each person at
whose request and for Whose benefit work is perf6rmed underor pursuant to
any permit issued. as, a result of thisappiicatori agrees to, & shall, indemnify
& hold harmless the City of La Ou'inta, its officers, agents and employees.
2. Any permit issued as a result of.this application becomes null. And void if
work is not . commenced withiri 1-8'.0 days I frorTi.dat0. days will subject 06Ae of issuance of such.
o
'Permit, or cessation
- I . 1f work for 1 8 0 it to cancellation.
I certify that I have�rpacl this application and state that the above information is
correct: I agree to comply -with all City, and State lawsr6lating to. the building
construction, "and hereby authorize representat es of this City to enter upon
the above-mentioned prbper�for,inspection purposes, ,
blgnature r
(GWi16r/Ag an t)D.-, i
BUILDING PER -MIT PERMIT #WW2_416
DATE VALUATION &?A0.1 PAO LOT 17 TRACT 291W.
JOB SITE 9-5 65 VISTA CAUCO
4
ADDRESS
'1APN
OWNER
CONTRACTOR DESIGNER / ENGINEER
rp 4wnwin,
Fo AQX 1,116
'ry-295 IM4CHO LA QU ADR_
LA QULWEA CA 922-5-1
LA. QUINTA CA 02253
('1,60p'n-194j. CP,,L# 299, 6,
USE OF PERMIT
-L& T I'll 154E E2GR-,PFXMT-J00L- S, M HiCLUDE FIL OCk. WjUIS, OR
POOL75OX; PLAN ORECK FEE REDUCTICYN FQ.Rtv1ULTiI4LE !SSUAINCE G+
SAME, PLAN *1`V'PF_
-v c 317,
dmro, yws m ur,
GAKINUWCARPORT 1'
r A ir mmn Ml 0 N
v S Im"'a. mr,\ MSror "L sr.gw
249,11710
P11151 -H, it F P11 f 11, S lu Mimi A RY
CONKI'RUCTION FEY, 101 -NO -418-000
L.0, N ("14 --F of z� F M, , n, 2. 7,1
N 4& 3" -0 400 P I,AMICIIANICAL REM, .101,000 4130:`.0
I
a Z clTi i C AL I F E -Z. . 101-000-4M_000.
101-000-419-000 5175.15
1-01-000-M-000
101-000-423-000 x
DEMAC)PER %4PA4;f M,
w-wientAcEs msm -701-000-25s-000 $350.29
.Aii.
SUB-1-11MALCXYINT A F! c1mck
$414
.110,1110N -ND
LESS. P.R.E, -RAID 011.
T01'Al., PERWf Bi EM DUE NOW
RECEIPT
DATE
Y
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
— —oz a ew-
Return Air
Steel
Combustion -Air
Roof Deck
Exhaust Fans "
O.K to Wrap
F.A.U.
Framing
Insulation
�
Compressor
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
le 674
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 . p
Utility Notice (Perm)
COMMENTS:
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