9704-060 (BLDG)LICENSED CONTRACTOR DECLARATION
07 I hereby affirm under penalty of perjury that I am licensed under provisions of
1 .. 'Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
CIJ W Professionals Code, and my License is in full force and effect.
O Z) cM License # Lic. Class Exp. Date
�a� {{t yy
ZLIJ
Q / Date Signature of Contractor
T_
C° FZ rn OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ CU) License Law for the following reason:
Z_ ( ) 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).
C`') () I am exempt under Section , B&P.C. for this reason
Ln
O C\JN Date Signature of Owner
rn
0- Q WORKER'S COMPENSATION DECLARATION
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
r O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
Q J Q performance of the work for which this permit is issued.
coQ CD 00 1 have and will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
d M permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
000
0
J (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: 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
4 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
PERMIT# CONTROL#
BUILDING PERMIT
97411*. 4981
DATE t wt VALUATION LOT TRACT
JOB SITE
ADDRESS .. 414) 01NIAS Is I' RV E I'
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
SH RIAIN
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USE OF PERMIT
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I.i°!St't'lll .UE'D (I)ST CDC CONSTRUCTION
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LESS 11RE- PAIL? FEES
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
•a.w
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE I 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.
Fireplace P.L.
Grills
Fireplace T.O. Fans & Controls
Partv Wail insuiatien Condensate Lines
Exterior Lath
Drvwall - Int. Lath
POOLS - SPAS
BLOCKWALL APPROVALS
steel
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
heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Gas Test
COMMENTS:
I Final
I ELECTRICAL APPROVALS
TemD. Power Pole
Low Voltage Win
Fixtures
Main Service
Sub Panels
Exterior Receptac
G.F.I.
Smoke Detectors
TemD. Use of Pa
Final
Utility Notice