9802-051 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04W Professionals Code, and my License is in full force and effect.
=) Cn License # Lic. Class Exp. Date
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uI'tdDl�f 111 1P-9
Z ti Date L ! � `' 1 "' Signature of Contractor
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C) OWNER -BUILDER DECLARATION
H Wd ti s
I hereby affirm under penalty of perjury that I am exempt from the Contractor's'
U) License Law for the following reason:
Z ( ) 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. 7044, Business & Professionals
Code).
C'`) O I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION
� I hereby affirm under penalty of perjury one of the following declarations:
F-; p () 1 have and will maintain a certificate of consent to self -insure for workers'
K W U compensation, as provided for by Section 3700 of the Labor Code, for the
J Qperformance of the work for which this permit is issued.
n Q (� (_.) I have and will maintain workers' compensation insurance, as required by
j U Q Section 3700 of the Labor Code, for the performance of the work for which this
1 rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
It z Carrier Policy No.
Cb 5
g (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
3 subject to the workers' compensation prQvisio6s of Section 3700 of the Labor
Code I shall forthwith comply with those provisions.
Dater t �" /('Applicant
Warning: Failure to secure Workers"C�mpensation coverage is unlwWul and
shall subject arnemployer to criminal penalties and civil fines up to $100000, 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 applicator agrees to, & shall, indemnify
map & hold harmless the City of La. Ouinta, 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 upon
the;above-mentioned prop6rty for ection/purposes.
/ignature (Owner/Agent)_
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PERMIT PERMIT# °ONTR°`#
.BUILDING
DATE VALUATION ;i>l 41.9ii3 1;0 LOT' TRACT
6822
JOB SIT#
ADDRESS��ti
OWNER
CONTRACTOR/ DESIGNER / ENGINEER
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LAQUI %VI'A. CA (01 3
LA QtllNl'A C'A.
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USE OF PERMIT
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e59 i F{iR N41LILTIPLtH ISSUANCE C)F SAlbf}. PLAN TYVFt PAID
APR
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MEICHiVNICAL FE1 101 •gat) -da 1 -NO ".il+ti �1fI
ilii:+"Pith'AL FEE 101-000-420-000
PLUM,NiNG FEE
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ART IN Pf!t` LK'.' K,ACTl *N - 70.11,0(10( 23;-00f1 Sttis'Z.fa)
St it3-TC1'I`,A1, (,'ON fT'T?.liCTiC: N :F\NP t't.-A N t"1•(M,CX
$5, _'srix S7
LESS 111::E PAW 1"1213-S
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RECEIPT
DATE
BY /
DATE FINALED
INSPECTOR
HSIPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
SULDNG
APPROVALS
M ECHAMCAL APPROVALS
Set Backs
'.ZG 1 Q/ it
Underground Ducts
Forms & FootingsDucts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
L
Exhaust Fans
O.K. to Wrap
-7. 22- U <
F-A.U. -
Framing
Z 7-
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 Q=
Final
4
POOLS - SPAS
BL®C4C@f ALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PILURflMMG APPROVALS
Gas Test
Electric Final
Waste Lines
- (�il
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
'6 -
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
-
Appliances
Finalnnnn�n
pa cc
C®douun EMTS.
Final O
Utility Notice (Gas) -
ELECTMCAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels -
Exterior Receptaclzs
G.F.I.
Smoke Detectors
Temp. Use of Power
Primal
UiiNy Notice (Perm) _(f,