9808-032 (SFD)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 DATE
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
JOB SITE
o ADDRESS
i
date r �r Signature of Contractor - �, OWNER
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.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance cf 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
subjectlto the workers' compensation provisions of Section 3700 of the Labor
Code; I shall fortl�Vith comply with those provisions., fI
Date: Applie.2lnt
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 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/Agent) ! Date
USE OF PERMIT
BUILDING PERMIT
VALUATION LOT
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N1TY OF L�i QUINTA
RECEIPT DATE BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION I DATE 1 INSPECTOR OPERATION ' DATE IINSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs I� � Underground Ducts
Forms & Footings /�''tv �'v" Ducts
Slab Grade — ._�T� Return Air
Steel Combustion Air
Roof Deck �re�( . (_ Exhaust Fans
O.K. to Wrap f r J 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 7 CI
Final ' 7
SLOCKWALL APPROV LS
Final
POOLS - SPAS
Steel
Set Backs
i
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 _ �.—��
�7.
Heater Final
Water Piping
Plumbing Final
Plumt. ,.rp ,Lcp Out
_
Equipment Enclosure
Shower Pans
l
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
I Gas Test
%
- -- — —I COMMENTS:
Final
Utility Notice (Gas) —
I
I
ELEC`47RICAL APPROVALS
Temp. Power Pole
Underground Gonduit
Rough Wiring
!_
Low voltage Wiring
�
—
Fixtures
Main Service
Sub Paneis
Exterior Recei :::ties
G.F.i,
Smoke Detect—S
Temp, Use of Power
Firm—