0108-218 (BLCK)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 my License is in full force and effect.
License # Lic. Class Exp. Date
1
/Date `, Signature of Contractor
OWNER -BUILDER DECLARATION
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 Owner
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. '
()r) I 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.
MATE FUND IM2304-00
(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
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply wit h.:thos&,provisior f
Date: J,� >/ Applicant r r� .,�!-•��ri° ;'',�t�f%/'>
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for.inspection purposes.�J'
,,,,Signature (Owner/Agent)r 4�' •i" i!.• "� Date
BUILDING! PERMIT-. PERMIT#
DATE VALUATION LOT TRACT
( Mm. :920LOG
JOB SITE
APN
ADDRESS
ST -M) -M) R�ddp99;`�14tTtl��yy,A y� yy 7�}e{{"qq
3W V,MS•I"9.CiRP.s .Yti,G.% ,:), �.+
OWNER
CONTRACTOR/DESIGNER/EN &NEER r
73.177 AMBER Vrld f
dba Cil. DDEWRT C_.OM&M
r3JDIAN WF?US CA 92210
pA1..M )DRASM G,A. 92260.
(760)771-R.409 C".£3i. f Ml
USE OF PERMIT
s
'N 1-K 4' PROFANX L?,i+a(.LZ)SURtt-C1'TY' SPANDAK'I)
4 Ff. WA A.L
EXTIA"M CO ST OF CON's-IRULM ON
111F$ti'.3ATF IM 9EM€t£ ARY
CONSTRUCTION FELE � 101-000-416-000 31S*
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AUG 2 2 200
C'Ty OF
NANCE QUIN PA
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RECEIPT
DATE .•; %
BY
DATE FINALED
INSPECTOR '
jrI s
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
f
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
Forms & Footings }
Ducts
Slab Grade f
Return Air
Steel
Combustion Air
Roof Deck f
Exhaust Fans
O.K. to Wrap ;
F.A.U.
Framing 1
Compressor
Insulation j
Vents
Fireplace P.L.
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall I
Exterior Lath I
Drywall - Int. Lath I
J
1 •
f
Final
Final 1
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs ! 7
Electric Bond
_
Footings 1 — / _
Bond Beam 1 _y v ( S�
I
Main Drain
Approval to Cover
Equipment Location
I
Underground Electric
J
Final ) lQ C/� ��
Underground Pibg. Test
Gas Piping
ING
PLUMBPLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans I
O.K. for Finish Plaster
Sewer Lateral J
Pool Cover
Sewer Connection 1
Encapsulation
Gas Piping )
Gas Test I
Appliances 1
1
Final
J
I
Final I
Utility Notice (Gas)
ELECTRICAL APPROVALS
f
Temp. Power Pole'
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures 1
Main Service I
Sub Panels
Exterior Receptacles
G.F.I. I
Smoke Detectors j
Temp. Use of Power
1
I
Final i
Utility Notice (Perm)
COMMENTS: