PLBG (0209-211)LICENSED CONTRACTOR ONTRACTOR DEC I L A R . ATIO N1
I hereby affirm under penalty of perjury that I am licensed under provisions.o
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and', -.1,.:,
Professionals Code, and myticense is in full force and effect.
License # Lic. Class —2lExp. bite
B C36
0. 2-,
Date 2 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 infen8ed or offered for. /,
sale (Sec. 7044, Businelss4 Professionals Code).
1, as owner of the property, am exclusively contracting with, licensed
contractors to construct the project (Sec. 7044, Business & Professionals-/
Code).
O I am exempt un6;r,'5ecfion 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-insrure foirworkers'
compensation, as 'provided fo,r'by Section 3700 of the Lab& Code, for the
performance of the work for which this permit, is issUpd.
I have and will maintain workers' compbnsati" dn insurance, as required by
Section 3700 of the Labor Code, for the perfo6ance of the work for which' this
permit is issued. My -workers' compensation insurance carrier & policy nd-are:
Carver Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performanceof 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 3700 of the Labor
Code; I shall forthwith comply with thodprovisio'ns.
,13 -ate: Applicant—
Warning: Failure to secure W6rkers' 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.
IMPORTANT Application is hereby made to the Director of Building and Safety'
for a permit subject to the conditions and restrictions set forth. om 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 applibaton agrees to; & shall', inclem hify
& hold harmless the City of La Quinta, its officers, agents'an*d 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',§uch
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 authorizerepresentativesof this City to enter upon
the above-mentioned property for inspection purposes.
I -
Signature (Owner/Agent) Date
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CITYOFLAQUINTA
FINANCEDEPT
'RECEIPT
DATE
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
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
POOLS - SPAS
BLOCKWALL APPROVALS
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
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
Appl ?noes
Final
COMMENTS:
C ,�� rl
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)