9712-107 (RPL)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
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Date gnature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1 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 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.
( ) 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 Policy No.
AINT;
(This section need not be completed if the permit valuation is for $100.00 or less).
O I- certify that in the performance of the.Work_for which this permit is issued,
I shall not employ any person in any manrer.so as to become subject to the
workers' compensation laws of Califomi and agree that if I should become
subject to the workers' compensatiop/p ovi'sions of_Section 3700 of the Labor
Code, Itsh II forthwith comply with t ' 6e provisions.
Date: '� g7Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1.00,000, in
addition to the cost of compensation, damages as provided for in Section 8706
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
IlWach person upon whose behalf this application is made & each person at
request and for whose benefit work is performed under or pursuant to
it issued as a result of this applicaton agrees to, & shall, indemnity
& rmless the City of La Quinta, its officers, agents and employees.
2. it issued as a result of this application becomes null and void if
work I 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 f&Iinspection purposes.
Signature (Owner/Agenty, a Date r
BUILDING PERMIT PERMIT 1iSZ.40► CONTROLM
DATE I !f °�Jy l VALUATION LOT TRACT G 6 3 9
ADDRESS 73.970 y::i�:•\ DEL W.0 JOB SITE APN ale
OWNER CONTRACTOR/DESIGNER/ENGINEER
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USE OF PERMIT
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RECEIPT I DATE J „ L,7 ..� I BY / I DATE FINALED I INSPECTOR
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NSPEC T OM RECORLP
OPERATION DATE INSPECTOR
BULMMIC APPROVALS
OPERATION 'NSPECTOR
MECHAMCALh APP.
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
Find
SLOOKWALL,L APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
`
Underground Plbg. Test
Final
Gas Piping
P[LUMENG APPROVALS
Gas Test
Electric Final
12
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)
ELECT MCAL 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
Fiinall
Utility Notice (Perm) -- — `-
COWNENTS:
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