0209-079 (PAT)`.
,
LICENSED CONTRACT ORDECLARATION
| hereby affirm under penalty ofperjury that |omlicensed under provisions of
Chapter 9 (commencing withSection 7000) of Division 3 of the Bvoinmm0o�_e
,.Pmfeooiona|oCode, and. License
�nmand effect.
License # . uo.class Exp. Date
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OWNER -BUILDER DECLARATION
I hereby affinnunder penalty ufperjury that |amexomphumthe Contractor's
License Law for the hdlowireason:
( ) 1, as owner of the property, or my employees with wages as their
solecompensation, will do the work, and the structure is not intended or offered for�
-.-sale (Sec..7044, Business & Professionals Code).
1, as owner of the_property, am exclusively contracting, with licensed
contractors to construct the project (Sec. 7044, Business &,Professionals
I am exempt under Section B&P.C. for this reason
Date� of Owner
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^-.NsR'S COMPENSATION DECLARATION ~' '
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| hereby affirm under penalty of perjury one of � followingdeclarations:
. () | have and will maintain ocertificate ofconsent mself-insure for workers'
'compo��o . as provided for by Section 3700�mo ��w�� for the
=b�mo,mammmthe work for which this permit ioissued.
( xmmand vwn m�moinwnnmo/oompono��n insurance, as required by
Go�o'Romoovthe Labor Code, for the performance of the work for�wm�mis
permit is issued. My workers' compensationinsurance carrier & policy no. o:Carrie I Policy No.
(This section need not becompleted if the permit valuation isfor $10l00mless).
]) |.certify the performance of the work for which this permit isissued,
| shall not employ any person in any mann�,so as to become subject mthe
| womoWoompensation laws o/-Can^,mia. and agree that i, | should become'
"subject to the workers compensation provisions ul bection 3700 ol Me LaDor
Code I shall forthwith comply Wlih those
Warning: Failure msecure Workers' Compensation coverage isunlawful and
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shall subject anemployer mcriminal penalties and civil fines uptp$1m\000 in
ddition to thecost mvcompensation, damages ooprovided for inSection 37oV
v/the Labor Code, interest and attorney's fees. `
IMPORTANT Application is hereby made to the Director of Building and Safefyfor " permit """p^` o the conditions~and restrictions ~~` forth*^on
1.Each person upon whose behalf this application mmade meach '
w ose'eq est an O~_~^e~�~r�^~
any permit isouod as oresult orthis oppicatonagrees to, & shall, indemnify
& hold harmless the City ox La Ouintu, its offioors, agents and employees.
' u.Any permit iqovod as result ofthis application becomes null and void if
.work is not commenced, within 180 duyo.,,nm Uoto of issuance o, such '
permit, o,.ce0000ionofwo,k'ho, 1uodays will subject permit tocancel ,oion."
|certify that |have read this application and state.that the above information is
correct. I agree to hh allCity, and. State laws relating the building
construction, and hereby authorize `representatives of this City to enter upon
the above-mentioned property for ins,�cfion.purposes.
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1411 BUILDING PERMIT
VALUATION LOT
TE r,- TRACT
JOB SITE
APN
ADDRESS_ 79475 WAlaVOK.LD CIRMF.
QWNER
CONTRACTOR DESIGNER ENGINEER
Ulm IT
LA QUNTA CA 0-2253
PALN6.10RIUMV CA !92260
cm-O)so,9200 MU 560.
-USE OF PERMIT
PORCIVRATIO SF
PLM CIIIJECK FU( 10) -ON-43 9-3 18
CcrKSTPIMIM."I'M REP. 10-1-060-418-006
STRONG MOT1011 FEE REM D 101-000-241'.000
1X03 PM,
41
s
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 'l - L
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
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:
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