0210-004 (SFD)r
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
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 owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). i
( ) I am exempt under Section , B&P.C. for this reason
Date i 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 Y );1'UND Policy No. t'4644270007338
(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 provisionseof Section 3700 of theLabor
Code, fl shall forthwith comply with those/provisioris.,..-r' I
.,,Date:' - .r *0,0 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 t D
any permit,issued as a result of this applicaton agrees to, & shall, indemnif
;& 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 i
' work'is not commenced within 180 days from date of issuance of. suc
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 i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter up
the above-mentioned property for inspection purposes. r
'Signature (Owner/Agent) ti r Date e" ' z '
;rBUILDING PERMIT PERMIT#
#
DATE VALUATION LOTTRACT
% U • _7' c 7 $24o.1 17.1,0 1. 2.94V-3
JOB SITE -
ADDRESS 79.-951 XURCHO LA QtrMT.%DRIVE
APN
& 4q„ /"00 240
OWNER
CONTRACTOR / DESIGNER / ENGINEER
M DEM Wr DF-MM017A•t1E33 T
FSO BOX 1716
79=295 RANCE10 !AQU"rNTA DR.
LA QUINU., CA 92253
LA QU:tNTA CA 92253
(160)771.19411 MUH 2991,
/
USE OF PERMIT
SM -,WT T 1, ENCA TO 2: PERMIT DOES. NOT KC:f.UDt BLOCK
WAU.0, Int 114, SPA, OR DRYV'EWAY y!1.1?E'➢$rJACH, IN C''.8C, NNW );"), Y1, Y
POfti,IVPA:TIO 235-00 Sig
C3ARAOWCARPOU 41M.09 8F
91;
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
J/— i —v
Ducts
Slab Grade
— J
Return Air
'
Steel
Combustion Air
Roof Deck
— ,� _
Exhaust Fans
O.K. to Wrap
-3
F.A.U.
Framing
—
Compressor
_
Insulation
/_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
'
Final
—
Final/—
BLOCKWALL APPROVALS
Steel
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
/ — D� �-
Heater Final
Water Pipingy)
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:
/