0312-136 (BLCK)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 ExpeDate
64981 F� � �/o
1f31l22
r
Date t 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:
( ) 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
r
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 S .l-j`•Pi'" Policy No. 1.54292"43
(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 tha 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: 1-7 ; Applicant-- fir
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 pursua
any permit issued as a result of this applicaton agrees.to, & shall, inde i
& hold harmless the City of La Quinta, its officers, agents and emplo
2. Any permit issued as a result of this application becomes null and v i
work is not commenced within 180 days from date of, issuance of c
permit, or cessationofwork for 180 days will subject permit to cancell do .
I certify that I have read this application and state that the above informa on is
correct. I agree to comply with all City, and State laws relating to the b
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned prope4 for;inspection purposes.
/Signature (Owner/Agent) * � �--� Date q,
BUILDING PERMIT PERM T#
DATE VALUATION LOTTRACT
JOB SITE APN
ADDRESS 5x-A%pNaM yAg6,
OWNER CONTRACTOR / DESIGNER / EN (NEER
COROAT.T1.. ENMRPIUSES t °C fzabwL C"C)LdFfRM1.101T
X) BOX 389 51-1 JS ,A MMA i TJdA 0.101
LA, QiT;! TA CA 922$3 L.k QUTN1'A CA 9225.3
(760)W-4604 Cato 2.261
USE OF PERMIT
GEREML 'rsT 13L1 IA1"(
43X..F.5't.Al'D?,N'WAL.1,r'q1'rY5TA1+10. Rr)
Y
1 FT. WALL
4.00 WF
ESTIMATED COFF OF C049132nur-MION
FIRMWr1' MIMPly
CQN'T1tUM10N ITS 101-000-418-000 X25 DU
SDR -TOTAL 'CONSTR1 �+C ON AM PLAW C13E..0r... $25.90
L�1JINTA
111M, PRE -PAID $0.00
SJ:�® Ji,� .y.l+' A',ESL+S9�~/� ��Y' Sa• tNs � W.7�J..L� ®W' - - �t'Y.:r�
DEC 15 ITY OF LA �Z, UFINANCE DE
RECEIPT DATE BY "� DA FI ED INR
VFt.e. �.' SP aG ..
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
OX 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam o
Approval to Cover
Equipment Location
Underground Electric
Underground Ptbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Unes
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 r
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)
COMMENTS:
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