9809-152 (RPL)LICENSED CONTRACTOR DECLARATION
hhereby that I am licensed under of
PERMIT# CONTROL#
BUILDING PERMIT
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affirm under penalty of perjury provisions
�Cha�ter 9 (commencingwith Section 7000 of Division 3 of the Business and
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DATE / VALUATION .Tft,t,i��ir).t�tl` LOT TRACT Q 7
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Professionals Code, and my License is in full force and effect.
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ADDRESS i$t-b /. �l�►a91� Pt!n�J 111111APN
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OWNER
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OWNER -BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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PHOENIX A7, 14
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License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
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compensation, will do the work, and the structure is not intended or offered for
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USE OF PERMIT
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
POOL AND/OR SPA
contractors to construct the project (Sec. 7044, Business & Professionals
CY)Code).
() I am exempt under Section B&P.C. for this reason
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Date Signature of Owner
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COMPENSATION DECLARATION
WORKER'S
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I hereby affirm under penalty of perjury one of the following declarations:
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O 1 have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are:
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Carrier VPolicy No.
STAM FUND 11013_r1_111011
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(This section need not be completed if the permit valuation is for $100.00 or less).
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( ) I certify that in the performance of the work for which this permit is issued,
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I shall not employ any person in any manner so as to become subject to the
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CON,811�t,YIGN PA 00 101-M)-AIR-0�1.15,fT(1
workers' compensation laws of California and'agree that if'I should become
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sub'ectt to the workers' compensation provisions of,Section 37,00 of the Labor
C�dde, I shall forthwith comply.with those pr Visions.
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v6ate: �� %%. • : yApplicant / - ` �' �'' �-^^4-�._ _ �__
PLUMB040 Flag ._ V(Xc)£, t011 -WO -419-000 $47.0(1
Warning: Failure to secure Workers' 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 on his
application.
1. Each person upon whose behalf this application is made & each person at ;c
whose request and for whose benefit work is performed under or pursuant to, t
any permit issued as a result of this applicaton agrees to, & shall, indemnify
SUB -TOM. C ONS MUC:'i'1ON AND PLAN CIMC .
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& 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
la1?SS k'.X2IC-EyAlD FEES
work is not commenced within 180 days from date of issuance of such �
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permit, or cessation of work for 180 days will subject permit to cancellation.-
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I certify that I have read this application and state that the above information is
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corre ct!1 agree to comply with all,City,-and State laws relating to the building
construction, and hereby authorize representatives o this City to enter upon
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th for ins
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above-mentioned property p' ion purposes.
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RECEIPT
DATE
BY f
DATE FINALED
INSPECTOR
ignature (Owner/Ag )-�:-:�X Date���
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
/G.
Set Backs
Electric Bond
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Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
_ G
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
COMMENTS:
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
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Final
Utility Notice (Perm)