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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
113 0A W
Date `? "? Signature of Contractor`
+
OWN ER-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 maihtain`a certificate of consent,to self -insure for workers'
compensation, as provided•fo� by.Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(!) 1 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 .V'.tlT1tFUND Policy No. 1703624 -o",
(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 provisions.
Applicant-,
Warning: Failure to secure Woreers' 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) '" P'- �' ='�= »�- Date X -;'•-t< 6 3
BUILDING PERMIT PERM'
DATE VALUATION fy+; l' LOT ) TRACT R f
JOB SITEa. .f •^ a f`'�F
ADDRESS
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OWNER
CONTRACTORDESIGNER / ENGINEER
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AUG 11 2003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE w ''
BY
DA ,11 D�
1 PECTOR
a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR -
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
—
Ducts
Slab Grade
Return Air
Steel
3
Combustion Air
Roof Deck
Exhaust Fans
O.iC to Wrap
Framing
Insulation
✓
�
�
F.A.U. 40
Compressor
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 A ROVALS
POOLS -SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
(Perm) i
Equipment Location
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR -
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
—
Ducts
Slab Grade
Return Air
Steel
3
Combustion Air
Roof Deck
Exhaust Fans
O.iC to Wrap
Framing
Insulation
✓
�
�
F.A.U. 40
Compressor
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 A ROVALS
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 APPROVAL
Gas Test
Electric Final
Waste Lines
Heater Final •
Water Piping
v
Plumbing Final
Plumbing Top Out
-
Equipment Enclosure
Shower Pans
O.IC for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
�
Appliances
Final
-
Final
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 -,
Utility Notice
COMMENTS:
'
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