9701-048 (MISC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of.perfury;that I arri-Iiicensed 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;
Lice;seq# ..p Lic. Class Exp. Pate p
Ybate (� ! 7 Signature of Contractor
OWNER -BUILDER DECLARATION
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).
O 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;
• O 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:,.
(a -1 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
sub jecf to the workers' compensation pr�lslons of Section 3700 of the Labor.
Code, I shall forthwith'comply with those provisions:{y,t :. r
Date: 1-61101 Applicant
Warning: Failure to secure Workers' Compensation 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
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'resultof this.applicaton agrees to, &.shall,' 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 arid -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'informatlon is
correct. I'agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives.this City to enter upon
the�above-mentioned property,fo'r inspection purposes
tVSignature (Owner/Agent):F�"e�� 1-;,j Date
PERMIT # CONTROL #
BUILDING PERMIT'.
45$1
DATE 11,01P r VALUATION �ry;.;� ;r�: LOT TRACT.
`
JOB SITE ADDRESS -IN!3ro.X1Ci1\tii#a
APN
OWNER
-y�
CONTRACTOR / DESIGNER /ENGINEER
qi 1` �
LAAA T [
1.itl.C�yl.igi. 5r��0IX.39r1kkVrE1.S" . ..
p try S �+ 7 �•.
� f}'1..1.yj.S!11f."�. I(71,.
1ryP..1..=L. •i�IyVl'.
`�r
.. j! (: 1.[YY�;+.
p4tL'•_t�.\f tiii�}'1
y�4
3226 r. 4kf1-1e)L711V�..7 ON BLV.W.
USE OF PERMIT
t't✓s1Yf'F'lifl ild 'r i:`¢ #1s l�,TtS'q C�t3 t3 i13tlapvrL'inkY.SLM.CLA$SfC. LO AT-101,
tV f»4t.lsAfk 1t2:3 -. !�11r h :ite'11r Ck2k l�JS.
TC?:F CO NUMION
2,#itL:�iD
PR+�+�il ff :. !; Sl<;tj09MAR
`3PE`C, I A1,1 N$.F-+V,( fbJ 101-000-n 3-0clo R 100.01)
_svES,�; PRE -PAW FEUTSV1,00
:. • .
J'AN 0.9 1997 .
;.. TOTAL-PER._1% t. € saERS DUE NOW'
y OF LA auINTA :"6
CI
RECEIPT.
DATE
BY. ^ -
DATE ALE
INSPECTOR
INSPECTION RECORD,'_ 41
_,, OPERATION
DATE
INSPECTOR
OPERATION,
DATE
SPECTOR
` a.. BUILDING APPROVALS
MECHANICAL APPROVALS
- Set Backs
Underground Ducts .. -
Forms & Footings
Ducts
Slab Grade
Return Air
Steel, •
Combustion Air
Roof Deck
Exhaust Fans
s
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
x
Exterior Lath
Drywall : Int. Lath
^'
Final
F_
t Final
, . • _
-'POOLS- -.SPAS.
=: BLOCKWALLIA90116VALS
Steel
-.
Set Backs
Electric Bond,
Footings,
Main Drain
{
Bond Beam
Approval to Cover. =
Equipment Location
- -
Underground Electric
Underground Plbg. Test,
Finale
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final'
-
Plumbing Top Out
Equipment Enclosure
Shower,Pans
0.K.,for Finish Plaster
Sewer Lateral
Pool Cover
• Sewer Connection
Encapsulation
Gas Piping
! -Gas Test'
r
r ' Appliances
Final
COMMENTS:.
'
r ,
-
+,
.;
'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.l.'
Smoke Detectors
_ -Temp. Use of Power
Final
Utility Notice (Perm)