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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
Bate d' Signature of Contractor re" {`" :•,"
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury 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 am exempt under Section W.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofi perjury one of the following declarations:
( ) I have and will maintain a certificate of con"sent 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.
(tib) 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 STATE F11XD Policy No. 370'3624-O
r
(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 with those prgvisions-
Date: '" • ' 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 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) w fir!/ """" " - % Date t-
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BUILDING PERMIT PERMIT#�
DATE 1 r, VALUATION LOT t TRACTJOB
SITE
ADDRESS '�,�-L4.��SF�U+CD:�?.
APN �tt3SL,fn^L�9
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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JUN 022003-
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DAT.Et
BY *� E�FI
INSP TOR
v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms& Footings
Ducts
Slab Grade
Return Air
SteelCombustion
Air
Roof Deck
,
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls 10
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
i
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
PLUMBIN9
APPROVAL
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 A WVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring 011
Fixtures
Main Service
Sub Panels (10
Exterior Receptacles x
G.F.I.
Smoke Detectors -
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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