0107-055 (BLCK)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
i
Date
mtractor '
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:
Carrier Policy No.
OTATE FUND 1376409 -OD
(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.
Date: "1�! -s"J Applicant
Wa_rning--FllUre to secure Wor cl"ers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties anti 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
fora 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 inspection purposes.
Signature..(Owner%Agentj''- ""` Dated/
'BUILDING, PERMIT PERMIT#
DATE VALUATION LOT ��� Y�_E%'J TRACT
JOB SITE
APN
ADDRESS
;M�15 'SAGITE#R0 DR.
(Y* -;41 "J 4
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MP. 1011.t)00
Y HOMM
11370 AVENMABERWIUM.
53.'70AVIN.1:4%ADERMUD.d.
LA. Q:10INA CA 92253
LAs. QTJ'WrA Cts 92253
(160)564-1962 C B1;ff 6255
USE OF PERMIT
CYooz-A& J LcU IC>
210 LAV 6' 0AR,DZ?4 TR3 ALt..
OR.016'`I'i>wNWARD . .
E Vii. ''i�.AsM, d11s, LF
FWWWATED COST Ole CONSTRUC11x00
'
RMI'F. SUMMARY
CONSTRUCTION MR 101.000.416-000
MVSTILIATION KZE 101,000 -423. -CM
D
K
CITY OF lAQU1NTA
FINANCE DEPT
R'f B -IN '1:AL COJti'e^� RUC'°:t',1C).M AND S7LAR CMC
$162.00
1XIS Pyr. (PAID F=4
$0.00 1
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
.1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
C
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 4
Underground Ducts
Forms & Footings i
Ducts
Slab Grade I
Return Air
Steel I
Combustion Air
Roof Deck I
Exhaust Fans
O.K. to Wrap •
F.A.U. -
Framing I
Compressor .
Insulation I
Vents
Fireplace P.L. I
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath I
Drywall - Int. Lath I
1
}
1
Final
Final I
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs I
Footings I ! —�2 O—� ST
Electric Bond
Main Drain
Bond Beam_ I
Approval to Cover
Equipment Location
I
Underground Electric
1I
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
>
Gas Test
Electric Final
Waste Lines I
Heater Final
Water Piping i
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral l
Pool Cover
Sewer Connection
Encapsulation
Gas Piping )
Gas Test ]
Appliances J
1
Final
]
COMMENTS:
--
I
I
Final J
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring I
Low Voltage Wiring
Fixtures J
Main Service i
Sub Panels }
Exterior Receptacles
G.F.I. I -
Smoke Detectors!
Temp. Use of Power
J
Final J
Utility Notice (Perm)