BLDG (0106-245)LICENSED CONTRACTOR DECLARATION K
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 # h. Lic.'Class Exp. Date
r t
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:
I, as owner of; he property, or my�employees with wages as their sole
cgmpensation, will do the work, and thd'structure is not intended or offered for
sale (Sec. 7044; Business & Professionals Code).
( ) I, as owner of ;the prop>y, arn'exclusively contracting with licensed
contractors to construct th4 project (Sec. 7044, Business & Professionals
Code).
O I am 'ezempt under Section ' B&P.C. for this reason
Date Signature of i0writr
�,.
.ORKER'S COMP S/ALP�ON DECLARATION
I ierepjiaffirm under penalty of p rjury one of the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, asprovided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) 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.
(This section need not be' completed if the p!F a atlori is for $100.00 or less).
() I certify that in the performanceof�he work for which this permit is issued,
IAall not employ any person In manner so as to become subject to the
Workers' compensation laws: California, and agree that if I should become
subject to the workers'grpensation provisions of Section 3700 of the Labor
Code, I shall forthwokcomply with thos, provisions.
•War%ning.�Fail'ure"t'o"secure WorkeFs'"Compensation coverage is unlawful and
,shall subjeca
tn 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.
IMP.ORTANT`iApplication is hereby made to the Director of Building and Safety
for a perm iir subject to the conditions and restrictions set forth . on his
application.
1. Each person upon whose behalf this application is made & each person,at t
whose. request and for whose benefit work is performed under or pursuant to
any permit, issued as a result of this applicator agrees to, & shall, indemnify
& hold haimless the City of La Quinta, its officers, agentsand employees.
2. Any permit issued as a result of this application b@Gomes null and void if
Work is. not commenced within 180 days from. -date of issuance of such
permit, or cessation of work for 180 daysyo iirsubject permit to cancellation.
I certify that I have read this applic'atiop-and state that the above information is
correct. I agree to comply with �kC ti y,. and State laws relating to the building
construction, and hereby a theorize representatives'of this City'to enter, upon
th.b above mentioned pope y for inspection purposes. _
Date
BUILDING PERMIT PERMT#
DATE VALUATION LOT Q%.":xN'�'J' TR,,
JOB SITE
APN
ADDRESS
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
MX311113��WAPIN3
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LA QUWA (,A -.0022;53
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USE PERMIT
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iY,l%1.V•.;•CLS.89J../ Jti�•k.".! r .�h.7
30 V 4"UPTAINNG WALL
4 FT, WALL AN LF
ESTMATM5 €:.",jr OF CC?ASIRUMON
480.00
CONSTRUCTION F 0100
t
ti
$15•00
LEW PTS PAA) IMS
$0,00
7FMAY
ECEIP. : CITY OF
L0A Y
DATE FINALED
INSPECTOR
Fl iA
CE DEPT,% j%,/
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
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party!JVall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
I 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
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
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
COMMENTS:
/
C`
Sulk Panelsw
�jiirior ^ptacles
jctors
>>e of Power
P ,
rnal
';'pity Notice (Perm)
46, / j"_U