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LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensededer 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 effe6.
License# Lic. Class Exp. Date
'193216 B, '0313il C.
Date Signature of Contractor At _
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).
( •) 1, 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.
V) I have and will maintain workers' compensation insurance, as required by
S coon 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:
'°I�.Jr' FUND Policy No. � OMI I
(This section need not be completed if the permit vaidation is for $100.00 or less).
( ) I certify that in the performance of the work fo_ riwhich t lis permit is issued,
I shall not employ any person in any manner so as to bedome subject to the
workers' compensation laws of California, and agree that If I should become
subject to the workers' compensation provisions of`Section13700 of the Labor
12ode, I shall forthwith comply with thpkprovisi ns
Date: 4oDlicant''^ \, G. +
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees..
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result, of this application becomes null and void if
work is not commenced within 180 days fr 'date of issuance of such
permit, or cessation of work for 180 days willfiubject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply witt Aall City, and Stpte laws relating to the building
construction, and hereby autoorize representatives of this City to enter upon
the above-mentioned.propeftJor i%sp do rposes.
Signature (Owner/Agent)
��• Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ���� ��� TRACT
JOB SITE
APN
ADDRESS •. C°A:�A y)7 :. SC?A..
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
DAVM "i I i C;OMM.iFG"}' 014
JI)VIX!,'t-.7014ER 010)q5,``i't:t• r37(:'!W
P.U. BQX 17'12
P.01.1_ ox 177
LA (;fUwr.A. CA 9275:3
T. A Qi,1Kto CA, 92 253
"If -o)275=3s:Z3
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USE OF PERMIT
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4 F71. WAL1 00 LY
4 FT. WALL, 103. W IY
CITY
OF LA QUINTa
FI
ANCE DEPT.
k:1S'F'fA_tt rJ ) C106Y OF C'UN'KT:R?`.ff^'i':EON
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C'01`fa'1'RUC7'1GN FRIP 101-00 0-41$-000 sa1.CU
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ir!2:9 PRE-PAIDP.l?:ES
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TOTAL 111-R.Mrf MES 011F NOW
R401
RECEIPT
DATE
FINALED
INSPECTOR
it z
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
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
BLOCKVVALL APPROVALS
POOLS _ SPAS
Steel
Set Backs
lJ
Electric Bond
Footings
(,
Main Drain
Bnnd Beam
c
Approval to Cover
Y,- d .Got
Equipment Location
O / f p milli
Underground Electric
Underground Plbg, Test
Final
I
Gas Piping
PLUMBI NG APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
0. K. for Finish Plaster
Sewer Lateral .
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTR-- aCAL 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 (Perm)
COMMENTS: