0205-198 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Imo- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
LLJ � 7011039 ja kW, — r ✓ 3 01131/20
oZ r1_Date'_ `� '� Signature of Contractor—,
(D 0 F
J U OWNER -BUILDER DECLARATION
HWIZ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
CV) () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
p C\
Q 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 TAUt bl". > Policy No.
(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 it I should become'
subject to the workers' compensation provisions! of Section 3700 of the Labor
Code, I shall forthwith comply with those provlsionsr
Date: rl �s !,` Applicant-
-Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful 4nd
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.
a
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 forinspectlon purposes.
�. Signature (Owner/Agent) 1 >• /jAL'Date
31
BUILDING PERMIT PERMIT#
QD�i4�••dC-�
DATE VALUATIONLOT r TRACTJOB
SITE
ADDRESS 4"40 Rli#. CUO SAT �AX� J.�
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PM 1.A. Q.lJ 1*,A, �-1..�
TRANS WEST :H0iMNG INC
69 HMlS:i T strkw
Ill
SAND1600 CA 52131
i./41.QC.T.MA CAS 922.53
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QWJ171.33,63 C131A 4972
USE OF PERMIT
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K106.95
CITYOFLAQUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
NSPT;
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
p
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
_
Z, Z
Exhaust Fans
F.A.U.
Framing
— / —p
Compressor
Insulation
oy
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
_ _
Condensate Lines
Party Wall Firewall
Exterior Lath
-� O
Drywall - Int. Lath
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
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
Plumbing Top Out
r ��j _C
_
/��
Heater Final
Plumbing Final
Equipment Enclosure
Shower Pans
ZO.K.
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 _
Fbdures
Main Service
Sub Panels i
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: