0107-174 (RR)LICENSED' CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury,that I am -licensed under provisions of
Fes— Chapter 9 (commencing with Section 7000) of Division 3 of -the Business and
04 W . Professionals Code, and my License is in full force.andeffect:* t
C License # Lic. Class • Exp. Date '
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Z ±1 i t Signature of Contractor
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J U •OWNER BUILDER DECLARATIO
11J W I hereby affirm under penalty of perjury that I, am exempt from the Contractor's
~ a ` License Law for the following reason:
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-� Z (,) 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).
�fi, "` (•) I, as owner of the property, am exclusively contracting with licensed
` contractors to construct the;project '(Sec. 7044,' Business & Professionals
Code).
I am exempt under Section B&P.C. for this reason
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Date' Signature of Owner
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Q WORKER'S COMPENSATION DECLARATION
p cc hereby affirm under penalty of perjury one of the following declarations:
Lo H: C) O L:have and will,maintain a certificate of consent to self -insure for workers'
X W LL compensation, -as provided for by Section 3700 of. the Labor Code,, for: the
m J Q "performance of the work for which this permit is issued: `
Q C) ( )..1 have and will maintain, workers' compensation'insurance, as required by
O'v;Q ;Sectlori 3700 of the Labor Code,' for the" performance of the work for which this
"a I.— s''� permit is issued. My workers' -compensation. insurance carrier & policy no, are:
Z Camey Policy No_ w
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Q (This -section need not be.completed if the pennit valuation is for $100.00 or, less).
( ')'.•I;certify that in the performance d,, the work.for which this permit is issued,
`. I all not employ any person in any manner sous to become subject to the
workers' compensation laws, of California, and agreethat'if 15should become
3 •subject to. the, workers' compensatlowprovisi6ns of Section 3700 of the Labor Code, I shall fo hwltn comply wit those'provlsions:
Date: .Applicant'
* `Warning Failu tosecure W..o ers ,CpensaU coverage is unlawful and
shall subject an employer to criminal pen Ities and Ivil fines up to $100,000,' in
addition to the cost -of compensation, da ages 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 as a result of this applicatori agrees to, & sliall, 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. I agree to comply with all City, and State laws relating to the building
construction, and hereby'authorize representatives of this City to enter upon
the above-mentioned,pra er for inspeection purposes. ' '
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I SianQtwra (^wnor!Agent)� i Date" !.
BUILDING PERMIT PERMIT#
.•' r . VALUATION LOT TRACT
DATE
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JOB SITE �"_"
ADDRESS
APN
:49-140 Nam Tvmilt -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PO WX 799
3462 E 1MPANA WAY
R"Cla.0la cit, CA 02270
PALM &RNGS : +A 92262
(760)416.5977 CRIX 4293
USE OF PERMIT
RE -9001?- RIC 1C.8O d#i' TW30 - lPt". L URF."!'HANS .F+i)AM A4 ACZYl.,.lC.
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SUB. -TOTAL CC)N*,,r CItD t6' �+ pale ix�%�Sq�iCy. �y+p y, p":
$30.00
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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.... ., ,.... ._ _. .�--•.. _.._f""r. ._-.. .. _ �. ! - .fin.
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 8'_ - O/ ,S
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 =�p j --
BLOCKWALLI.APPR V
O ALS
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
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)