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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
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:
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 COMPENSATIONDECLARATION
I hereby affirm under penalty of perj ury 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.
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.
"T
31 V011,17-010.)
(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 I become
subject to the workers�'compensation,provisions of Section 3700 qt the,.,Labor
CoA, lshall forthwith comply with t os provisions
Applicant -
11P �ie
Warning: Failu re 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
I�Pose request and for whose benefit work is performed under or pursuant to
any permit issu ' ed 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
A
construction, and hereby authorize representatives of this City to enter upon
, " I
the above- menti oned property/Jor inspection purpqDses!
L,Sfgnature (Owner/Agent) 2i���Date
P
I PERMIT# -
BUILDING PERMIT
DATE VALUATION LOT TRACT
(Il"fq
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JOB SITE
45-uio colam"cloK
ADDRES8
1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i;NT1,Ir% 1.01k%Atm,
T1qr-0% 0-t-Nop
i,282 W. ARROW.141%W11
i 282 W. ARROW' 1114ry
UPLAND CA 141,185
MIAND (-,A 91785
USE OF PERMIT
I, I I " ?LA:N 40.4,, -,PIERMIT D0EJ1.,Iiar M-NOODS WALL
U"D, L077
(At POOL..
&RAC3' CONSTRUTC,rb.01; 1,14 i 1 100 41r1V
1k*C1H/11Xr10 70.0
11"'TrMMYED 01S I.R.0011 CON, it A I.%
PERMIT VOK SUMMARY
11CONSIMA-MI'M FEE 101 -WO -419-000
KAN 14) �_W_ _41NI-3 � 9
A163 1AINICAL - FIM
rIDE(_. MACAL _r9f.. 401,-W�4204M
1111UNW40 FIE 101-000-419-M X) 4 S. 110
-WRONQ PIAKMOX REE - PIA811T) *! 0 1 4W-24! -40.
GRINDT11.101111 FUM $210.00
DEVELOPFR LWACT FER
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L.E.SS Y124-PAIDPETS
If ffrikL PERIVIR FF13118 OVENOW
RECEIPT
DATE
BY
DATE FINALED.
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
A/5
Ducts
Slab Grade
6' &Z
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K. to Wrap
z - .1
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
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
J_
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior RecWacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: