0006-005 (RR)LICENSED CONTRACTOR DECLARATION
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
627233 C39 0813112(.
Date Signature of Contracto
1 1
OWNER -BUILDER DECLA ION
I hereby affirm under penalty of perjury that 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).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of 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.
(V I have and will maintain workers' compensation insurance, as required by
Sn 3700 of the Labor Code, for the performance of the work for which'this
p it is issued. My workers'' compensation insurance carrier & policy no. are:
arri
STATES FUD Policy No. n5- 00 UNIT 812
(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 t should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forjhwith comply with o proviso .
Date: 1"..�t Applican
Warning: Failure to secure Workers' C pensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
'-..ofAhe 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 applicaton agrees to, & shall, indemnity
& 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
cons uction, and hereby authorize pre sentatives of this City to enter upon
the bove-mentioned property for inection p rposes:
ignature (Owner/Agent) 7 Date LU
PERMIT #
-UP BUILDING PERMIT
ATE VALUATION' LOTTRACT
JOB SITEp -' -.
ADDRESS 901W� %1611 p, CM=
am. .=i_D�-�y �.
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1&0NAnCH AGEh( NT
,'SIVA PACMC ROOFM
42-600 CAROLM COURT 9UiY'E 101
400 ><' 25111 qn0W
PALUDEMT CA 92211
UPLAND CA. 91784
(909)982-"l 1 CB1J0 -56M
USE OF PERMIT
GDW1tALBU1Mn40 •
r
Riff.ROOF 019LY•REId ME =W 010 WOOD SHINOLC& REPLACE WITH "
DECRA T119 ROOF (ICB.0 SR MOO) CLASS A FIRE RATING ONLY:
VALUATION 11,M.00 lis
SS.[TNIATM CCW OF CUINSMIDMOR
FXRh9r FEE 9O1 AW
RZROOF In " 101400th -418.000
SUB -TOTAL CONOTRUCMON AND PLAN CIMCK
$34.00
LM M -PAID IN=
MOO
TO'T'AL PMW FM DUE I'T(?114%
130AV
RECEIPT
DATE
B
DATE FINALED
INSPECTOR
/r _
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
(g. i Wit
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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)