9902-045 (RPL)LICENSED CONTRACTOR DECLARATION
reby affirm under penalty of perjury that I am licensed under provisions of
I.apter 9 (commencing with Section.,7,PDO) of Division 3 of the Business and
-Professionals Code, and my License s in full force and effect.
6901577 C.S.3 C27 6/3-0
i/bate —1 Signature,of Contractor AM
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
dcen�& Law for the following reason:
1,as owner of the property, or my employees with wages as their sole
cc,mpensation, will do the.work, and the structure is not intended or offered for
sale. (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sed. 7044, Business & Professionals
J).:.] 'am ex'empt 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'
cbmpen sation, as, provided for by Section 3700 of the Labor Code, for the
pe�rformance of the work for which this permit is issued.
I (�. )*- I have and will maintain workers' compensation insurance, as required by
S6ction' 3700 of thei Labor Code, forthe performance of the work for which this
permit -.is: *issued,'My wo rkers' compensation insurance � carrier & policy no.' are:
Carrier - Policy No.
`(This section need not be completed if the permit valuation is for $100.00 or less).certiiy� that in-theper'formance of the work for which this permit is issued;I Shall not *employ any person in any manner so as to become subject to theworkers'. compensation laws of California, and agree that if I should becomesubject to the workers' compensation provisions of Section 3700 of the LaborCode,'l shall forthwith comply with those provisions.Warning: Failure to secure Workers' Compensation coverage is Si�aul dridshall subject an employer to criminal. penalties and civil fines up to et 000, inaddition to'the cost of compensation, damages as provided for in Section 3706of the Labor Code, interest and attorney's fees.,114PORTANT Application is hereby made to the Director of Building and Safetyfdr: a permit subject to the conditions and restrictions set forth on his1. Each person. upon whose behalf this application is made & each person atwhose request and for whose benefit work is performed under or pursuant to,.�any.permit issued as a re ' sult of this applicaton agrees to, & shall, indemnifyhold 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 ifW6 . rk is.not commenced within 180 days from date of issuance of suchpermit-, 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�orr'ect., I agree to comply with all City, and State laws relating to the buildingconstruction,- and hereby authorize representatives of this City to enter uponthe above-mentioned property for inspection purposes.ture (Owner/Agent Date
PERMIT #
"BALDING PERMIT "OZ -045
DATE VALUATI ON
AL
SJ'7,4"�00 LOT TRACT
ADDRESS
OWNER
CONTRACTOR / DESIGNER ENGINEER
LA. QUO
CA 9W253
PALM DIED 330T CA 92260
5220
USE OF PERMIT
POOL
PLAN CHECK FLT&
1-000 430-318
�0420_000 $45,00
sul�--Teyr,XG CON' PD PIAN Cf
E SS PRE-PIUD FEES
T10.00
R
DATE FINALED
INSPECTOR
71,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & 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
Fkeplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
- —
Set Backs
Electric Bond
2-Z
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
Heater Final
Water Piping
^Plumbing
Plumbing Final
To,. ^ut
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)