SFD (9907-331)c LICENSED -CONTRACTOR DECLARATION
.I hereby affirm,under.penalty'of;perjury that I am•licensed under provlsions•of
Chapter 9:(commencing.with Section 7000) of; Division 3 of the Business and
Professionals Code and myLicense is in full force and effect. v.
License # Lic. Class . " E*.Date'
Date Signature of. Contractor
-r' •OWNER -BUILDER -DECLARATION }
I hereby affirm urider.penalty:of pertury•.that I am exempt from the Contractor's
License Law for the following reason: `
( ) I, as owner. of the property, or niy`employees with wages as,their.sole
compensation,: will do the work, and thetstructure is not intended oroffered,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:
() I have,and will maintain a certificate of consent to self -insure for workers'
co npensatio ,.:as provided for .by Section 3700 of the' Labor Code fo�'the
pe jo ce of: the work for which this. permit is issued
( I have and will maintain.workers'•compensation. Insurance, as -required by
Section 3700 of thb'L.aboF•Code,. for the'pe"rformance_ of the work for which this
permit is issued: My workers' compensation,insurance-carrier & policy no. are:
Carrier Policy No' ' yµ` C �}ay
45P -
.(This section need not _be completed if the permit valuation is for $100.00 orless):
( ); 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 betcome'subject to the
workers' compensation laws of.California, and agree that if I•should become
subject to the,workers'. compensatibnprovisions`of Section 3700 of the Labor
Code,' hs all orthwith comply with those'prov��F0
Date: pplicant ".y ••
Warning: Failure to secure Workers' Compensation coverage is:unlawful and
sfiall 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 restriction's 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 applicatoq agrees to, &'. shall, indemnify
& hold'harmless the City of La Quinta, its officers, agents and employees.
2.'Any permit:issued as a'result•oftthis application becomes null and void if,
work .is not commenced within 180 days. from. date of issuance of.such
permit,.br cessation of' work for'180 days will subject permit to cancellation:
I certify that I have read this applicationand 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 tb' enter .upon
the above mentioned propertyfo.i s ' ction purposes:
Signature' (Owner/Agent) • .',-Date -
B•U,ILDING PERMIT PERM.6��
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RETAIDY
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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 Deck
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
_� z/ �j _
Compressor
Insulation
- •Q/
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final-,25—�z 5
Final�—
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
— S— 2
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Fin l
—
Gas Piping
PLUMBING APPROVALS
_
Gas Test
Electric Final
Waste Lines
���� s'
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final - ZS- 0
Utility Notice (Gas) % — 3o _ 0
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)