0001-243 (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
N W Professionals Code, and my License is in full force and effect.
O 5 th
License.#_ •,• _ Lic. Class Exp. Date.-
W
c Z � Date -f nQ Signature of Contractor J
Z_�
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CCD OWNER -BUILDER DECLARATION
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W WW I hereby affirm under penalty of perjury. that I am exempt from the Contractor's
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).
t'')O I am exempt under Section B8lP.C. for this reason
N Date Signature of Owner
O0
a Q WORKER'S COMPENSATION DECLARATION
0 . (r I hereby affirm under penalty of perjury one of the following declarations:
H O O 1 have and Will maintain a certificate of consent to self -insure for workers'
K W compensation, as provided for by Section 3700 of the Labor Code, for the
Qperformance of'the work for which this permit is. issued.
Q U 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
permit is issued. My workers' compensation insurance carrier & policy no. are:
aITD ? Carrier "s Policy No. ;` 1
� C3
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 ecome subject to the
workers' compensation laws of Califo . ang, gree t at if I should become
3 subject to the workers' compensation pro 'sibns of S ion 3700,o Labor
�3 �e, I s l,tort ith comply with those ovisions.
Bate? ff �' 0 � Applicant ,
Warning: Failure to secure Workers' Compensation coverage is u awful and
shall subject an employer to criminal penalties and civil fines up to $it00,000, 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
ICU & 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 all City, and State laws relating to the building
construction, and hereby a thorize representatives of this City to enter upon
the above mentioned perry r ' ction p rp es. / r
l,Sgnature (Owner/Ag IV
DateZ'
BUILDING PERMIT PERMIT#
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DATE,46 VALUATION 4r r! 74<A�eL�i4► LOT /!) TRACT 27h5
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JOB SITE 49-.QS1J 4:. A i d. E6 DR i V +i:
APN tg 9_J1S0' -"b
ADDRESS
OWNER
DESIGNER / ENGINEER
)CONTRACTOR
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LAk Qj JIff l'A CA 92"J'53
USE OF PERMIT
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S31Z72.33
RECEIPTDATE
@fY �i� "�/
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
G
Ducts
Slab Grade
ME -4211—
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
a.
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
— a�
Drywatl - Int. Lath
_
Final V4"-
-
POOLS a SPAS
®LOCKWALL
APPROVALS
Steel.
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground P1bg. 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 Piaster
Lateral
Pool Cover
S rConnection
Encapsulation
Gas Piping
Gas Test
Gv
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) Lj
(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 Q 13-04
UtilityNotice.(Perm) ff— Q-pJ