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LICENSED CONTRACTOR DECLARATION
I hereby of that I am licensed under of
I
BUILDING PERMIT
PERMIT# CONTROL#
affirm?under•penalty perjury provisions
Chapter with of Division 3 of the'Business and
(commencing 9
p gith Section 7000 )
DATE VALUATION LOT
TRACT I� �+
Professionals Code, and my License is in full forcetand effect. �1
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License # Lic. Class Exp. Date
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/Date
JOB SITE
ADDRESS .' f 1111kGo DRIVE
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��" . Signature of Contractor r -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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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7$071 ASI'I:R DR..
License Law for the following reason:
Lt1 QUIN'I't1 CA 92253
Pf\I.ltl DESERT CA 9`241
( ) I, as owner of the property, or my employees with wages as their sole
OF,t1W1-f+073 CB1.9 1.120
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
B(fii.IANG
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section , B&P.C. for this reason
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Date Signature of Owner
(^= t>51') t�IONcRioll.'i'11.fi
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued. ,
-( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for wliich this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No. -
v1'A'P1s
(This section need not be completed if the permit valuation iS for $100.00 or less).
( ) I certify that in the performance of the work for whic�,this permit is issued,
I shall not employ any person in any manner•so,as to ecomersubject to the
workers' compensation laws of Californi �7�d agre'e1 at`if I should become
subject to the workers'-compensatio provi�ioi�s o�$rection 3700 of the Labor
Code, shall f•,rthwi comply withgt�seiprbvi "-'s.i'jl `
yDate: Applicantf.
Warning: Failure to secure Worker 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
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, indemnity
& 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 frojn date of issuance of such
permit, or cessation of work fo�1180 days will Iubject permit to cancellation.
I certify that I have read this appligation and st to that the,above information is
correct. I agree to comply with all,"City-and/ StIte�aws relating to the building
construction, and hereby al�thor' Off prespn�tives of this City to enter upon
/tal
e above mentioned pro Jhy t inspec n urposes.
gnature (Owner/Agen.
I/��'r�'~""„�'-" Date
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CEIPT DATE BY ' DATE FINALED
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INSPECTOR
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CEIPT DATE BY ' DATE FINALED
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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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. lath �y
Final
BLOCKWALL APPROVALS
Final
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
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
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
C .
L
Final
Utility Notice (Perm)
COMMENTS: .