SFD (9907-041)LICENSED CONTRACTOR DECLARATION
f ,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 # i! f/Lic. Class a xp. Date
�7r
�pt � 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'ownei of th'e' property, am exclusively contracting with licensed
contractor's to construct the project (Seca 7044, Business & Professionals
Code). `
O I am exempt under Section B&P.C. for this reason' ,.
Date Signature of Owner r
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty 'of. perjury one of the following declarations:.
I have4nd1wlill maintain a certificate of consent to self -insure for workers'
compensation„asiprovided:foe by Section 3700 of the Labor Code, for the
-performance of the work for which this permit is issued.
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 thati Lshould become
subject t? Ae workers' compensatio, rovisions of,Section 370) of the Labor
.
Coded shhalljfo with comply withtthose-provlslons� �-^---•-•�--t
J7 (l 1, s
Date: Applicant
.VWarning: 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•'CoOe 'interest and attorney's fees. #
IMPORTANT Application is hereby made to the Director of.Building 'and Safety
fora permit subject, to the conditions and 'restrictions set fort! bn his
application. t
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, 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 rewesentatives of. this City to-en/erpon"
the above -mentioned -property for -i spectionnpurposes
Si nature (Owner/Agent)! Date -
� PERMITk -
-BUILDING
PERMIT "rs7-".1
DATE VALUATIONi LOT TRACT
• is
JOB SITS
ADDRESS
APN
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S
OWNER. s
CONTRACTOR/DESIGNER/ENGINEER r
S411'(U0.1,. , nC. OINIw9'!�l`�iUGII N
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y ali.'295 14040 j�L�. �„jLANI i`[�DIL
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" f 7Qn1 17.1.1941 �:�3,?,9914
�•
USE OF PERMIT
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ISSUANCE OP a.AM7%:I• LAN 1 ypj99
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Gs.Al�fiGEICt�i3,�::IkT 11f1.4tU Sl�
F, AlAsTED CY-)ST OF CON TRWTION
8.30
351,=
3
r, ONSTi'tUC°►'iCaN FE 101._000�ilLw-OW $'1321.50
I
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c11 C. 'Kip F F .• IQI-00-420 000 " $2116.7111
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RECEIPT
DATE
BY I"�'
DATE FINALED
INSPECTyOR y
r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab GradeReturn
Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
(2-
Compressor
Insulation
- p d
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
'et/
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
p
'Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Q
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 / •Gjj
Utility Notice (Perm)