9907-382 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and m_ y License is in full force and effect. •+
License # Lic. Class Exp. Date
%- (/fir /c�JJLUi.
e ate Si nature of Contractor
t(%
9
OWNER -BUILDER DECLARATION ti
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owrier
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.
()6I 'have and will maintain workers' compensation insurance, as required by
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:
Carrier Policy No.
ROYAL f.."JS. . tit' i 1"r 31"":•'
(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
workgrs compensation laws of California, and agree that if I should become
su�lect to the workers' compensation/�prov.si • n 0"'
Sectio 3700 of the Labor
Qbde, I L' I f ith comply w th6se p oSE
ate: I r� Applicant ,
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
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 with all City, and State laws r9lating to the building
construction, and hereby authorize representativof this City to enter upon
thevabove-mentioned prope%for insp® V,)nXpur7ses.
1'Signature (Owner/Agent)' /0.7 Date
BUILDING PERMIT PERMIT
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DATE VALUATION i:;;xt;za�,y}te LOT S+ TRACT f,)}{V().rL
JOB SITE ADDRESS 7.9-A4I ;.AGA
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OWNER '
CONTRACTOR/DESIGNER/ENGINEER
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USE OF PERMIT , r
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RECEIPT `
DATE
F ,
BY
DATE FINALED
INSPECTOR
I
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/
O
F.A.U.
Compressor
01
_
Framing �- I� �
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_
Condensate Lines
Party Wali Firewall
Exterior Lath
-
Drywall - Int. Lath
Final tel- (2 CGU !'2'k
BLOCKWALL APPROVALS
Final
G%�Z
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
- coo
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
. �f
Appliances
Final
COMMENTS:
Final p.
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 2 �i
Utility Notice (Perm)