0002-451 (SFD)VPa's
.LICENSED CONTRACTOR DECLARATION
under penalty of. perjury that I am licensed under provisions of
mmencing with Section 7000) of Division 3 of the Business and
Code, and my License is in full force and effect.
License # Lic. Class Exp., Date
Dat — Signature of Contract
.,G =
r
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 owner of the property, am -exclusively contracting with licensed
contractors to construct the project (Sec.. 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C. for this reason
Date Signature of Owner r
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 LaborCode, for the
.\perfOmance of the work for which this permit is issued.
\.
(,4 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.
toA l t. J`i 15j1i1 ^'t. L
(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,��l,� all,f.o�rt�hw�ith comply with tho,�e-pr � i� ns.
Date��S /19 Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to ,the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to -
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers,, agents and employees.
2. Any permit issued as a result of,this application becomes, null and void if
work is not commenced within 180 days from .date of issuance of such
permit, or cessation of work -for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply. with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for in%spection urpos s.
Signature (Owner/Agent) /' Date`/��
BUILDING PERMIT
PERMIE$�$f$2 �3
CONSTRUl:`!16.1N FE6
101-000-419-{3UlJ
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DATE 1 - I VALUATION ' ;bp,'� y�fj !1„ �$ LOT
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4 TRACT 23773-4I�,
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JOB SITE
ADDRESS 4J-66.5 1 Pscf, COURT
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
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10,Y'AL 9'Ef`gMIT ➢i C.04i OUP, N0W 1 $3.648.08 '
RECEIPT DATE BY/%„��^• " DATE FINALED INSPECTOR
L"
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
T.et Backs
Electric Bond
Underground Ducts
Forms & Footings
Bond Beam
Ducts
Slab Grade
Equipment Location
Return Air
Steel
Combustion Air
Roof Deck
Gas Piping
Exhaust Fans
O.K. to Wrap
/ —60 ,j;�6__
F.A.U.
Framing
Plumbing Final
Compressor
Insulationy�
�a
Vents
Fireplace P.L.
Pool Cover
Grills
Fireplace T.Q.
Gas PlDina
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
gyp_
Drvwall - Int. Lath
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
Neater 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 PlDina
Final 11116161 1 Lvrr `
Utility Notice (Gas) thpj
ELECTRICAL APPROVALS
Temp. Power Pole
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
Final
COMMENTS: