0205-202 (SFD)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
f
701039 1. ° j 4;1'.1 0141;Ao
Date ^ Signature of Contractor
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).
( ) I, as. owncr:of the property, am exclusively contracting with licensed
contractors to constructrthe 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 WfA7yjgy1jM Policy No. =1141381, 41
(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,.prov_islons,.
Date: `� . �'r. ,t� Applicant—
Warning:
pplicant 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 enter upon
the above-mentioned property for inspection purposes.
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Signature (Owner/Agent) /'•�s. Date_
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT �gy
- �.U.7+•�y�.96.vi�TD 33 2064
!^:i
JOB SITE
ADDRESS ��iik�arT Ti:T1Ai�.`���
APN av�
OWNER
CONTRACTOR / DESIGNER / EN (NEER
I'M Let. i. L C,
TRANS WEST 1401 IS3NG lX1
9%V 1!J.E11_RT'8'6k I? f
78.401 F FITUBM. AY '~ R.i
14ANL)Mao CA x,4131
LA.Qi.,INTA, CA '3225:
C �tay7� a CHUr 4_97.2
USE OF PERMIT
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MYOF L.AQUINTA
FINANCEDEPT.
RECEIPT
DATE
a`f=
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR,
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts E
Forms & Footings
N
Ducts
Slab Grade
- (- D 7 L
Return Air
Steel
Combustion Air [
Roof Deck
_ L
Exhaust Fans
0. K. to Wrap
C�.�
F.A.U.
Framing
Zf-- 7p
Compressor r
Insulation
2 -v
Vents l
Fireplace P.L.
Grills f
Fireplace T.O.
Fans & Controls f
Party Wail Insulation
_
Condensate Lines ;
Party Wali Firewall .
f
Exterior Lath
Drywall - Int. Lath
-OZ
Final
_
Final _ b
BLOCKWALL APPROVALS
POOLS - SPAS {�
I
Steel [
Set Backs
Electric Bond I i
Footings
Main Drain [
Bond Beam
Approval to Cover r
Equipment Location ;
Underground Electric
Underground Plbg. Test i
Final
Gas Piping
PLUMBING APPROVALS
Gas Test I
Electric Final [
Waste Lines
Heater Final I [
Water Piping,
LPlumbing
Final [
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Server Lateral
Sewer Connection
! -
Pool Cover
Encapsulation ±(
Gas Piping
—
I
Gas Test
Appliances
_
1
Final ±[
Finalds
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring zo
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles (/
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) _T�; 94—!
COMMENTS: j
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