9707-130 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
N Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
5 ch License # Lic. Class Exp. Date
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/Date %� Signature of Contractor
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J U coo OWNER -BUILDER DECLARATION
WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason
Z ( ) 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),
0 O 1 am exempt under- Section B&P.C. for this reason
LO
N Date Signature of Owner
O rn
(L Q WORKER'S COMPENSATION DECLARATION
p � I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J JQ performance of the work for which this permit is issued.
m Q 0 ()C) 1 have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
a M H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Carrier Policy No.
JQ (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 pe tis issued,
I shall not employ any person in any manner so as to beco su ject to the
workers' comps sation laws of Califomt iar agree ate' I sh Id become
jubject toj& Orkers' compensation,provisi n Se ton 370 of the Labor
Code,•f� alhfdl# . comply with those I Ions.
Date: {ii 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 enper..up n
2t e above-mentioned prop Fly for i ect' rposes.
V Signature (Owner/Agent) .� c� DatY`,
BUILDING PERMIT PERMIT# CON
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DATE VALUATION 5137-682.40 LOT ko - TRACT y51 y,t
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ADDRESS %M. 875 CA SA .7.1�!,L MCA
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:RECEIPT
DATE
7DATE
FINALED
INSPECTOR
0JHGPECTM RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
SUS LDWG APPROVALS
MEC6 ANiCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap UZZI -77
F.A.U.
Framing'3O
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 49 UL
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROV LS
lWaste
Lines
lWater
Piping
nalPlumbing
Top Out
qupmenEnclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral too
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
U014 Notice (Perm)
COMMENTS: