0111-049 (MISC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N LU Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
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W 'i£r8fi22d�f03 (1�2€
Z r` j Date � ,� Signature of Coni.—
actor-CD 0
J U C:) " "' OWNER -BUILDER DECLARATION
W w I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ 'a'^^
VJ License Law for the following reason:
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
ce) () I am exempt under Section , B&P.C. for this reason
L
N Date Signature of Owner
ON
Q)
CL z WORKER'S COMPENSATION DECLARATION
C) cr I hereby affirm under penalty of perjury one of the following declarations:
Lin � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U (, );:I have and will maintain workers' compensation insurance, as required by
C5 U Q `§ecfion 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier ENMPT Policy No.
cb Z)
CY
Q (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those -provisions.
Date: 1&1 •% V Applicant
�I.—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 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, 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 property for inspection purposes.
y� r
Signature (Owner/Agent) �`'Date
BUILDING PERMIT PERMIT#
DATE 7, VALUATION ^ LOT TRACT
JOB ADDRESS r i AVf, A..M,*0.N lM7,M1'A
APN ..
OWNER
CONTRACTOR/DESIGNER/EN (NEER
VI4'3:6'AVE BUILI)ER3
MOSP3.VE BUILDERS
71. --69811*11WAY 111
17 2.898 .HIGHTWAY 3 `I I
IAQt1:IT'1A CA 92253
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4360
USE PERMIT
sO��FTT� p�y� qty
3UPFLLMXNTA.L TO 0104„ 423 tvHAN09 OF C=C,I RA TOly
E MAM COST OF C0116111U :' 70111
+0.00
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7..102 �1�•'-P FERV
$0.00
A
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 peck
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
BLOCKWALL APPROVALS
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
Showar 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:
,
SITY OF LA QUINTA SUB -CONTRACTOR IST
JOB ADDRESS �' " �0��ZG PERMIT NUMBER OWNER 2' BUILDER O�
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of hiiilriinn nPrmit_ For each annlicahle trade. all information reauested below must be completed by applicant. "On File" is not an acceptable response.
Trade / Classification
_ Contractor
tate Contractor's License
Workers Com en§ation Insurance
Cit Business license
Company Name
Classification
(e.g. A, B, C-8)
License Number •
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xxl
License Number
(xxxx)
Exp. Date
(xxlxx/xx)
EARTHWORK IC -12) ...
CONCRETE:(C=8)
FRAMING IC -5)
STRUCT- STEEL IC -51)
V
MASONRY (C-29)
'
PLUMBING (6-36)
LATH, PLASTER IC -35)
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lUl
7
DRYWALL (C-9)
ELECTRICAL.IC=101
ROOFING.(C=39); `: ..
SHEET METAL (C-43) :.
FLOORING (C-15) '
GLAzING IC=17Y.
INSULATION (C-2)
SEWAGE DISP. (C-42) ,
PAINTING IC -33)
CERAMIC TILE (C-54) . .
CABINETS (C-6)
FENCING (C-13):
LANDSCAPING (C-27)
7/ /
POOL IC -53)O)"
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