SFD (9805-139)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury, that I am licensed under;p"rovisions 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 # t Lic, Class , Exp. Date
/Date ] Signature,of Contractor 1 -'
OWNER -BUILDER DECLARATION
I hereby affirm underpenalty 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 owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7.04.4, Business & Professionals
Code).
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION, DECLARATION
1 hereby affirm under penalty �ofti perjury one of the following declarations'.
O I•haye'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.
(jO 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.
S17ATE FUND 437109"gi p
(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.ifl should become
svblect to the workers' compensation provisions of Section 3'700 of the Labor
Code, J shall forthwith ompl nwith thos.pjo�ns.App � �1 }
Warning: Failure to secure Workers' Compensation coverage is unlawful nd
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 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 alb City, and. State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon .
the above-mentioned property forf inspection purposes. /
"Signature (Owner/Agent) (�'
—�-''? Date
PERMIT #-:
BUILDING: PERMITta���:<A
CONTROL #
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DATE ;, VALUATION - 1i2fi ;4�5 fi: ♦ d� „LOT, . ' ' 6p, . TRACT • . -27 j 17
JOB SITE
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OWNER .
CONTRACTOR / DESIGNER /GwENGINEER
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USE OF PERMIT ••
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RECEIPT
DATE"l
Lf_J
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
7--
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap/
F.A.U.
Framing
Compressor
Insulation
37-
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
Waste Lines _
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower 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
Pole
Underground
Under round Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
l
Final
Utility Notice (Perm)
COMMENTS:
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