0201-019 (BLCK)LICENSED CONTRACTOR DECLARATION'
I hereby affirm under penalty of perjury that I am licensed under provisions
Chapter 9 (commencing with Section 7000) of Division 3 of the Business a
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
2=31. 13 C36 04e 11A31(A
Date / I t ' c Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractc
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sl
compensation, will do the work, and the structure is not intended or offered
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licens
contractors to construct the project (Sec. 7044, Business & Profession
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 declaratiol
( ) I have and will maintain a certificate of consent to self -insure for worke
compensation, as provided for by Section 3700 of the Labor Code, for t
pVrr,rmance of the work for which this permit is issued.
i Ilhave and will. maintain workers' compensation insurance, as required
Section 3700 of the Labor Code, for the performance of the work for which t
permit is issued. My workers' compensation insurance carrier & policy no. a
Carrier 20TICATEFUND Policy No.
(This section need not be completed if the permit valuation is for $100.00 or les
() I certify that in the performance of the work for which this permit is issu(
I shall not employ any person in any manner so as to become subject to t
workers' compensation laws of California, and agree that if I should becor
subject to the workers' compensation provisions of Section 3700 of the Lak
Code, I shall forthwith comply with those provisions.
Date: d• ```�' +`',—Applicant 'y;__?
V.
Warning: Failure to secure Workers' Compensation coverage is unlawful a
shall subject an employer to criminal penalties and civil fines up to $100,000,
addition to the cost of compensation, damages as provided for in Section 37
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safi
for a permit subject to the conditions , and restrictions set forth on I
application.
1. Each person upon whose behalf this application is made & each person
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicator agrees to, & shall, indemr
& hold harmless the City of La Quinta, its officers, agents and employe(
2. Any permit issued as a result of this application becomes null and voic
work is not commenced within 180 days .from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellatic
I certify that I have read this application and state that the above information
Correct. I agree to comply with all City, and State laws relating to the buildi
construction, and hereby authorize representatives of this City to enter up
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) 'y� f`� Date,. 1J,'
fy
of
PERMIT PERMIT#
nd
_BUILDING 0201-0,119
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DATE � VALUATION g�,, per, LOT TRACT
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JOB SITE
ADDRESS .�':�� 1� aJ 1/trl
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OWNER
CONTRACTOR/DESIGNER/EN INEER
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RECEIPT
DAT !
BY----� F'
DATE FINALED
INSPECTOR
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
O.K. 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
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
Q.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
,
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)