9909-056 (BLDG)LICENSED CONTRACTOR DECLARATION
_I •hi�eby 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:
()0' I, as owner of the property, or my employees with wages.as their sole
compensation, will do the work, and the structure isnot 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 e tempt under Section B&P.C. for/thi'reas6n
�f5ate 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.
( ) rhave 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
�Xx 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
workersicompensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of S ction 3700 of the Labor
Cede; I`shall forth with,comply with those provisionpe
Zate: /- .2 ' Y 3 Applicant ____/ -, z Z , e,-: ---
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 att
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 Quihta, 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
thea o've-mentioned property for; inspection1purposes.
Ignature (Owner/Agent) 11L /- ' •✓� —. Date
PERMIT#
BUILDING PERMIT�>i_e�:;�
DATE ���I�6 VALUATION %LOT TRACT
JOB SITE
ADDRESS 78-707 SAM"O .DRIN E?
APN _
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JACK. Nr NON
OWNER ; Br IJ.DER
78707 tiA0UAlt0 DR
LA QUIN'rA ('1A 92253
C".2L0
USE OF PERMIT
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LUSIS PRF -MID FEES
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RECEIPT
DATE
BVINALED
DAT F
INSPECTOR
—/—
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
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROV LS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam -
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final — /r
Gas Piping
PLUMBING .APPROVALS
Gas Test
Electric Final
Waste Lines
Heater 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 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)