SFD (0301-017)04.
W tzE:
LICENSED CONTRACTOR DECLARATION
1 heeeby 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
B WCJ
Date ? ?�;� -- ��� r � .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:
'as owner of the property, or my employees with wages as their sole
corripensation, will do the work, and the structure is not intended or offered for
ial'e:: Sec. 7.044, Business & Professionals Code).
(,) „l,. as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code)
() 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.
(1) 1 have and will maintain workers' compensation insurance, as required by
SNion 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 FUND Policy No. 046-7;W-203
(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 provisions.of Section 'S3700 of the Labor
Code, I shall forthwith comply with those' -provisions.
,Date: Applicant ^�
Warning: Failure to secure Workers' Compensation coverage is unlawfuliand
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made -to the Director of Building and Safety
for a permit subject to the conditions and restrictions setforth on his
application. Pr`l
1. Each person upon whose behalf this application is made& each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall,.indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
Correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter,6pon
the above-mentioned property -for inspection purposes. 1
C 1"'" j
I Signature (Owner/Agent) - " J Date'
BUILDING PERMIT PERMIT#
`TRACT29457A3
DATE VALUATION _LOT ...��•,... � .=
ADDRESS 9 x AID,�$��,{�Fd.��1i�� 1GASI JOB SITE
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OWNER
CONTRACTOR / DESIGNER / EN (NEER
L (4mrrA CA 92253
Y..IA Q` NTA CA 9.225 3.
f; i 60YI71 -'1941 4 (MLA 2.996
USE OF PERMIT
$F)) " 10f PE"IT IDWES -2407' 114CLU:l,.ff;
CkO.� FTeS > �k X171 „{1k��'ii 1 tX. $�'�o I�I��`t:� C:[IFCK F'fr 1'
3E4.iTtCTICYN Fa3I,UI.iL.4°I'1lh,ISSUANCE OFStt9M PF -AN TYPE;
C;lISTOM CVMSTRUC;T1014 �,94114,e0 SF
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RECEIPT E_)TTTZZZZ==ZI
BY
DATE FINALED
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INSPECT
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19—
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_Z -
Ducts 7
Slab Grade
Return Air
Steel-
Combustion Air
Roof Deck
- O-
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
3 -
_
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
I I
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
Pool Cover
Sewer Connection
� 22 ... S
Encapsulation
Gas Piping
Gas Test
- !3
Appliances
Final
Final `
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service '7Sub Panels _
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final �2-
Utility Notice (Perm) =, _
COMMENTS: