SFD (0301-026)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
1514T/4 7m 1101
Date ' 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:
( )'." 1, 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:
. ( ) 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.
(j) • 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 STAT.F, ADM Policy No. tt�0:-"il�4J ?'0►��
(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
subject to the workers' compensation •provisionsaof Section;3700 of the Labor
Code, I shall forthwith comply with those provisions. '
bate: f•/ �. �. r x:� 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.
jMPORTANT 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 ursu
any permit issued as a result of this applicaton agrees to, & �Linfo[maficia-is—
correct.
& hold harmless the City of La Quinta, its officers, agents asr
2. Any permit issued as a result of this application- becomes if
work is not commenced within 180 days from date of iss of,�
permit, or cessation of work for 180 days will subject permit
I certify that I have read this application and state that the abovi �correct. I agree to comply with all City, and State laws relatingAconstruction, and hereby authorize representatives of•this CityA
the above-mentioned property fdr inspection purposes
J
Signature' (Owner/Agent) Date i
BUILDING PERMIT PERMIT #
Q3�fY&"-Z1r�ds
DATE VALUATION LOT TRACT
46 29f'17-3
„
JOB SITE
ADDRESS I9' ..C�t���e`aifY��..:�•k�:�
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PO BOX,1716
i 9-29.5 RAN tC'HO XA Qk3-'N'.i A DR,
C7 650)7111 194.1 c l -VII 2996
*"1
USE OF PERMIT
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SM o ieDT 4'f), KAX FZ KWI;s IT IDD .73 NOT 1idOJ. 1)'E—. BLOCK WA1.,t,w,
TMDTJCT1C rbf 'C 0X ,M`U't:•r1PLA iSSi7ANCT!, 0# smai,, i'f;,&NT-Ypv—,
CUSTOM 1/1�11'Iii3C11�J1 a9
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24%10,10
WNSARUC3ION REQ 101-000-418000 11,131170
KA'Xd'<('i:W,'.):.'PER 6232.34
MC:Pd;<N1C'A7.,1'"TE 101-000-421-000 5130150
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rit m 1k OT1014' 1rSP, , .(t.&S1D 1€31.000-212-C $x.01
ORADINO FEE 103 -M-423.000 145A
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ATC.f IN PUBLIC TILWIS -RESIL 27101-.000-445-009 $100.29
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QUINTA
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RECEIPT
DATE
BY
DATE FINALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings —,)!Z— 75
Ducts
Slab Grade 5
Return Air
Steel — Sr
Combustion Air
I
Roof Deck _ _ j
Exhaust Fans
_
O.K. to Wrap _
F.A.U.
Framing —/ 7— 3
Compressor
_
Insulation _ 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Party Wall Insulation /1
Fans & Controls
Condensate Lines
Party Wall Firewall C�
Exterior Lath
Drywall - Int. Lath
Final%-
BLOCKWALL APPROVALS
Final=J�
Steel
POOLS - SPAS
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 9
Plumbing Final
Plumbing Top Out /
Equipment Enclosure
Shower Pans /
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection — 3 --
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: