0205-175 (PAT)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
5,l? SWC
D�/ rrSignature of Contractor •-' ��� �x
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).
( ) 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:.
Carver 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 if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions:.
Dater !3 ,'� `i 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:''t
for a permit subject to the conditions and restrictions set forth on his F
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, indemnity
& 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 stat6 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
�habove-mentioned property for inspection purposes.
Signature (Owner/Agent) Date' 'L
BUILDING PERMIT PERMIT#
DATE ,� VALUATION "2 -AO LOT .4 _` a TRACT 22V55-2 y
JOB SITE _ APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN INFER
7A-591 PoIY m cgtfra 43.640 TEM8 ....
LA. M CA 92253 PALM I5ELtT CA. 9223.1
(760),360y3654 CSLR
USE OF PERMIT
GENERAL 110RDI G
1-1iO1Mf d'71,�I-0
12.1.00 NI
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AJL:t�1TfA�i " T1Ci SUM"Hy
H -M LI -EM -PSE 101-006-439-319
oC 'A ATG` i�#I`d'.l7 101-WO-41WtO i�i.Ott
,`a'k`.iG2t'S;NO XaCix7t W ACRE - SA) 101,000 -241 -OW $:169.
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RECEIPT DATEI BY rr DAT ALE j� _ I INSPECTOR
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61947160
WOO
9149.19
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 1'.
Underground Ducts
Forms & Footings I I
Ducts
Slab Grade I I
Return Air
Steel I I
Combustion Air
Roof Deck I i
Exhaust Fans
O.K. to Wrap iI
F.A.U.
Framing { {
Compressor
Insulation I }
Vents
Fireplace P.L. 11
Grills
Fireplace T.O. l l
Fans & Controls
Party Wall Insulation!
Condensate Lines
Party Wall Firewall 1;
Exterior Lath i
Drywall - Int. Lath 1 {
if
11
I l
Final
_
Final o -y
BLOCKWALL APPROVALS
r
Steel
POOLS - SPAS
Set Backs ] t
Electric Bond
Footings It
Main Drain
Bond Beam 1 f
Approval to Cover
1 E
Equipment Location
{
Underground Electric
] (
Underground Plbg. Test
i
Final t
Gas Piping
: PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines ! {
Heater Final
Water Piping I I
Plumbing Final
Plumbing Top Out ; E
Equipment Enclosure
Shower Pans ] 1
O.K. for Finish Plaster
Sewer Lateral I f
Pool Cover
Sewer Connection
Encapsulation
Gas Piping I f
Gas Test f
Appliances i!
I t
Final
It
fi
Final I I
Utility Notice (Gas) ! f
ELECTRICAL APPROVALS
„
Temp. Power Pole I {
Undetground Condut
Rough Wiring I
Low Voltage Wiringi I
Fixtures II
Main Service I I
Sub Panels 1I
Exterior Receptacles
G.F.I. I I
Smoke Detectors I I
Temp. Use of Power.
it
If
Final 11
Utility Notice (Perm)1
COMMENTS:
AM
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7
VY 7
CITY OF LA QUINTA
BUILDING-& SAFETY DEPT.
APPROVED.
FOR?O STRUCTION.
DATL�f_oq2 BY
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