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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
'Date • Signature of Contractors
OWNER -BUILDER DECLARATION
:I
I hereby affirm under penalty of perjury.,t'hat 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_111
() I am exempt under Section ' B&P.C. for this reason
Date Signature, of Owner I
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 bX Section 3700 of the,.Labor Code, for the
performance of the work for whicli4his 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 which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 2,7,s},'j`E. F rND Policy No. 130614 -03 -
(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,
t 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 ofh`6 Labor
Code, I shall forthwith comply with those provisions.,.--�
.-'Date: ` f yApplicant ild'.,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to crim nal 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,erriployees.
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.
Signature (Owner/Agent)., " -��-~ _ �_ Date 1
BUILDING PERMIT PERMIT#
Ct.3�.,-moi
DATE VALUATIONyy ip LOT . Vn 7. TRACT y f 1
t• i .1•Y n�,t. � 1
JOB SITE
ADDRESS Q3' -544 L>'s�i����%aC AUX .I}R VA.
APN
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
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USE OF PERMIT
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N -0 2 2003 .
Ei
CITY OF•LA QUINTA'
FINANCE DEPT.
�REC!EIPT DATE,
BY f,
D EF D
IN ECT
i
INSPECTION 11E00111)
OPERATION
DATE
INSPECTOR
OP RATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forts & Footings
Slab Grade V
Ducts
Return Air
Steel
Combustion Air
Roof Deck
O.K to Wrap ,i
Exhaust Fans
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
BLOCKWALL APPROVALS
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 APROVAL
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping ✓AMC
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection /
Encapsulation
Gas Piping r
Gas Test
Appliances
Final
Final
Utility Notice (Gas) 04
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 625
Low Voltage Wiring
Fixtures
Main Service
Sub Panels _
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 11 A
Utility Notice (Perm)
COMMENTS: