0107-173 (RR)LICENSED CONTRACTOR DECLARATION t
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
"t�� Ca.s9B r"-- „"'� dBYfi�
Date Siggature.of••C-ontractor ~Y
OWNER-EUILDER
I he�eby.affirm under penalty of perjurythat I. am exempt from the Contractor's
License Law for the following reason;
( ) I, 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).
( ) I, 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
1. hereby affirm under penalty ,of, perjury on�e,aof,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.
I>y 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 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 manner so as to become subject to the
workers' compensation _laws .of California, and agree that if I should become
subject to the workers' comperisa„tialm"ovisions of Section 3700 of the Labor
Code, I sh 11 ffo hwith cofnply with, os rovlsiV S� a
Date: . fp.a � A_ppllcant ,..
-» Warning.'Failure to secure Workers' Compe sationCIfi
era is unlawful and
Shall subject an.employerto criminal penaltie and civies upto $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.' r
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 as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, As 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. I agree to comply with all City, and State laws relating to the building
construction, and herebya tboriize reprreesse9tatives of this City to enter upon
the above-mentioned pro�y for inspectionip urposes
Sig naturo;(Qwnor/Agont) {- "-•°"`*Data 1�"^
BUILDING PERMIT PERMIT"
DATE '•'VAL'JAON LOT 0107-47,13 TRACT
JOBS
APN
ADDRESS �E1;�t22 q �p¢i y/� 1G 7��1q s7
48-7., d W'.k.1.11[.[A. DRQ �.Y9J.i�fil.
...
OWNER
CONTRACTOR/DESIGNER/ENGINEER
��r: k(C�1'!� T'Aw.�1i�.yT��. LA. PA7.' ii0A .
gip C i�kq%� :p T�t1lCflpOy1�+' NO
MA :�b�f
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3462 LA"�. S�i'].CVA.t"e'f�C' A l�Yic• Y .
VC'1.10 MEMM CA 922:70
PALM WRWOR CP. 92262
(760)416-afS".!7 CIBL , 4293
USE PERMIT
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UwRC, 011F.)ZTC 1CM 41i"PA630 > IND3A"UMTHMNE OM &ACRYLIC
CCA'1'6H0 '1100P3NO SYSTUM
4747.00 LS
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RECEIPT •
DAVE
BY
DATE FINALED
INSPECTOR
% $y %r/
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
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
BLOCKWAL APPROVALS
Final
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
.Dilater 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
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)
COMMENTS: