0303-137 (BLCK)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisior
Chapter 9 (commencing with Section 7000) of Division 3 of the Business
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Da�°"'te,
C}.arli - 13 S /,s 1137,
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L c. '�tti-vt,
Date a. J Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contrac
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their
compensation, will do the work, and the structure is not intended or offerel
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with (icer
contractors to construct the project (Sec. 7044, Business & Professio
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 declarati
( ) I have and will maintain a certificate of consent to self -insure for worl,
compensation, as provided for by Section 3700 of the Labor Code, for
performance of the work for which this permit is issued.
( )' I have and will maintain workers' compensation insurance, as require,
Section 3700 of the Labor Code, for the performance of the work for which
permit is issued. My workers' compensation insurance carrier & policy no.
Carrier 0TAf9 FUND Policy No. 1 1*4243'?-03
(This section need not be completed if the permit valuation is for $100.00 or le
( ) I certify that in the performance of the work for which this permit is issi
I shall not employ any person in any manner so as to become subject to
workers' compensation laws ofy California, and agree that -ifs I should bec(
subject to the workers' comperisation provisions of Section,3700 of the Lz
Code, I, shall forthwith comply withlthose provisions.
,,,Date: r_t W cr-�j Applicant''
Warning: Failure to secure Workers' Compensation coverage is unlawful
shall subject an employer to criminal penalties and civil fines up to $100,00(
addition to the cost of compensation, damages as provided for in Section 3
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Sa
for a permit subject to the conditions and restrictions, set forth on
applivatiun.
1. Each person upon whose behalf this application is made & each perso
whose request and for whose benefit work is performed under or pursuar
any permit issued as a result of this applicaton agrees to, & shall, indem
& hold harmless the City of La Quinta, its officers, agents and employe
2. Any permit issued as a result of this application becomes null and vo
work isinot commenced within 180 days from date of issuance of s
permit, or cessation of work for 180 days will subject permit to cancellat
I certify that I have read this application and state that the above informatio
correct. I agree to compIly,�vith all City, and State laws relating to the built
construction, and hereby authorize representatives of this City to enter ul
the above-mentioned property for inspection purposes
Signature (Owner/Agent) � Date
is of
BUILDING PERMIT PERMIT#MY4 3
and DATE ✓) ry VALUATION LOT TRACT
t041 JOB SITE ADDRESS m.,395 CALIZ QT,1I O APN .
OWNER CONTRACTOR / DESIGNER / EN (NEER
PO BOX 389 78-150 CAULETAW-5CO UUTM-92'10,
tor's L,,ps,Q'C!'!id'. A (:A 97.23:1 LA CA 92253
sole (760)5(A.-4604 (MTX{ 2261
J for
USE OF PERMIT
iced OFNERA ;.:BUILM Q
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DA`� BY �1 OATINALED ORRECEIPT_ �
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 6 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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
03
Electric Bond
Footings
Main Drain
Bond BeamApproval
_
to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
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)
ELECTRICAL 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: