0107-011 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that Cam 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. tClass le Exp. Date
q
p
Date f- Signature of Contractor' !r -ill_
`. \ 1
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.
I have and will maintain workers' compensation insurance, as required by
$e'"tion 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.
STATER FUND W-01-0010426
(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 personJnany manner so as fo become subject to the
s o
workers' compensation lawf Califdrnia, an),agree that( if I should become
subject to the workers' compensation pr'ovis'onslof Section 3,700 of the Labor
Code, I,sh II fort . w)'th comply with those ,prdvis'o , S.
Dte: t �-�` A licantii'' /t
VWarning: Failure to secure Workers' Cortloensation 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 haveread this applicationand state that the above information is
correct. I agree ito' comply with all City and Pate laws relating to the building
construction, and hereby autPorize, eprese..tatives of this City to enter upon
the above-meht,ioned property for Pnspectidn purposes.
Sfigriature '(Owner/Agent) jl ty . •'� yf%�+�---�" Datep
BUILDING PERMIT PERMT# ;
DATE VALUATION- LOT 0107-012. TRACT
I4 BigU5
JOB SITE
ADDRESS
:EN
OWNER
CONTRACTOR/ DESIGNER/INEER
MOR)~"3+bCJ V'Aia ET, Cr'y. 9253'
R1iP7;iitME CA 92508
USE OF PERMIT
GElle PJ i7EL it
23 .LV'A' OARDLN W:A A,C:ITY STANDARD ° +
Fr. WAL.+L x.00 LT'
r
4 rf. WALL, 2-5. 60 iLif
ISSIlIVY41LTED C061' OF C{)WNTRUK:`70N
5C51, 43. ,
PKII i I' MTE UUMMARV
( ONSTRUCT1011 FEE 1101-000-418-000 �3°Y.fi91
'A M, PLAN C'EMCK
$17.00 -,i� •n
ss
JUL PEMUFM, DUE NOW
j CITY OF LA RUIN iA
1 FINANCE DEPT
14
RECEIPT DATE j BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1
Underground Ducts
-Forms & Footings I
Ducts
Slab Grade I
Return Air
i Steel )
Combustion Air
Roof Deck }
Exhaust Fans
O.K. to Wrap 1
F.A.U.
Framing I
Compressor
Insulation 1
Vents
Fireplace P.L. 1
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation 1
Condensate Lines
Party Wall Firewall i
Exterior Lath I
Drywall - Int. Lath I
]
I
I
Final
Final t
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs J
Electric Bond
Footings ) :
Main Drain
Bond Beam 1
Approval to Cover
I
Equipment Location
}
Underground Electric
I
Underground Plbg. Test
Final }
Gas.Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines I
Heater Final
Water Piping I
Plumbing Final
Plumbing Top Out ` (
Equipment Enclosure
Shower Pans l
O.K. for Finish Plaster
Sewer Lateral }
Pool Cover
Sewer Connection ]
Encapsulation
Gas Piping i
Gas Test
Appliances ]
1
Final
I
I
Final ]
Utility Notice (Gas) }
a
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit ]
Rough Wiring I
Low Voltage Wiring J
Fixtures I
Main Service }
Sub Panels ;
Exterior Receptacles J
G.F.I. J
Smoke Detectors i
Temp. Use of Power {
I
{
Final ]
Utility Notice (Perm) l
COMMENTS:
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