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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
91 W A ignature of Con
te tractor
6
Oift /'�_ / 4
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
1, 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 I Labor Code, for the
performance of the work for which this'permit is issued. ,
I have and will maintain workers' compensation ins urance, as required by
S i
ec ion 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:
Cartier Policy NO.
ATE., 111UND,
III X19ZI I - I 9PS
(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;
1,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 the Libor
1 01
Code, I shall forthwith comply witfi`thoge provisions
DaI4� q,&6/zZ1Applicant_ AV 4.tega_ X/
7
VNarning: 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 compensaiion, damages as provided for in Section �706
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 a pplication becom es null and void if.
work is not commenced within 180 clay� 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 authori2re representatives of this City to enter upon
the above-mentioned property fo/r 4nspection p-urgoses.
�/ -, Pate
J Signature (Owner/Agent) A.4,e,
PERMIT#
BUILDING PERMIT
DATE VALUATION 1&0�1 TRACT
LOT
JOB SITE LAIN.0
PN
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
0192 W. AWWWINVY
1 .28 2 W. A RR 01 V 11 W V
UPLAND CA V085
UPLAND CA 14178�1
USE OF PERMIT
AS FANOLYOWELLWO
PI-3-tMIT DCAS NOT 1NCLW)EBLGCK
WALL OR t" & 7-srslo RVAAKTK�N ON PLAN CH W -,K 1-+-V FOR
43SUANCE' 01- SAN01PLANTYPS.
TRAC"T 00�P437"R.WrIONN 1,566M W,
599.4K1 8F
'FIRAMIT FEE 8.1J_1MfVhWy
CA.XN.S'r10X710N TAX 101AM-1USA") $63.5.00
KAN FIX I �!
3AINAV,141CAL I=
st is 1 29
mumbl-No 101 M)0419-111(" 3148.00
,OR A.TVN0 F0E
i%VEJIOPM� 17V91AC? Fuz $4r,'07A
15 1- U3 -7 T: T r I C C i N 11K r. F1 I C, I I U! 14 ANI P
9 . r-.% , r,
LESS PlIF-I'MD FEES
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"FOIAL PERNIff FUJUS OVE
RECEIPT
I
DATE
I . .
BY
I .
DATE FINALED
fINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_?r
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
o I 1) 5--6 0
Compressor
insulation
11 -ff
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
t 'S'
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
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
Ad- -1-f 7 6-,6t
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
JL
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduft
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: