0001-254 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
b— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
C 5 th License # Lic..Class Exp., Date
d trr4U7y is ()i;3lizVi
Lu
r --
r-- ZO relate Signature ofContrac4
r- i— 0 OWNER -BUILDER DECLARATION
LU a I hereby affirm under penalty of perjury that I am exempt from the Contractor's
C0 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 contiactirig with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code): I•
co () I am exempt under Section. , B&P.C. for this reason
O N Date Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
o1 hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor, Code, for the
O Q performance of the work for which this permit is. issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Seon 3700 of the Labor Code, for the performance of the work for which this
ti LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carver�,, t, „n" Policy No.
n �
J (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 ct to the
workers' compensation laws of Calif"a, agree that it sho become
subject to the workers' compensation provisio s of Secti 3700 f the Labor
Cordshall fo with comply wi ethose pr f /
D e: // - Applicant _
Warning: Failure to secure Workers' Compen coverage is unlawfu and
shall subject an employer to criminal penalties and civil fines up to $100, 0, 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
fora 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,witli all City, and State laws relating to the building
Construction, and hereby+autho9)))ze rep�sa tat' of this City to enter upon
the above=
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab GradeReturn
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 - GAS
BLOCK4f ALl L 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
Gas Test
Electric Final
Waste Lines
CIO
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection L
Encapsulation
Gas Piping
Gas Test
clks
Appliances
Final
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)
COMMENTS: