0401-222 (BLCK)LICENSED CONTRACTOR DECLARATION
W 'I hereby affirm under penalty of perjury that I am licensed under provisions of
i- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
fV W Professionals Code, and my License is in full force and
C 5 CO• License # Lic. Class Exp:, Date
Ln
r W 65? 188 t�}Tfi�'
oZ ti Date ��� ' Signature of Contractor
—I
I.—
cco OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from. the Contractor's
IL
IL License Law for the following reason:
Z ( ) I, as owner of the property, or my remployees 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 66'nt-racting with. licensed
contractors to construct the project (Sec. 7044, Business &` Professionals
Code). �.`
O I am,exempt under Section B&P..C. for this, real n
O N Date I le % Signature of Owner 'IJ e. ..—
rn
U Q 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.
(ti-) 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 18TATE COQ§P Policy'No. yfg319.01
(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'
subjecYto the workers' compensation provisions of Sion 3700 of the. Labor
Code, I'sha;l forthwith comply with'those provisions/'
Date: r! 1 �� Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shallsubject 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 ihis.application is made&:each personat
whose request and for whose, benefit work is performed under 'orpursua itJo
any permit issued as a.result of this appiicaton 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 160Aays will subject permit to cancellation.
I certify that l have read this; application and state thatthe above information is
correct;. l 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 foninspection purposes.
;Signature (Owner/Agent)- Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT AwbS-222 TRACT
JOB SITE APN
ADDRESS a-7t;'5AE►KNIf);f:tl: 7,41-141 -1412
OWNER CONTRACTOR /DESIGNER / EN (NEER
PAT..t'l: N9.M :twtiA10 DE01GIN :i:1.1 �,It3: 7<?.?3.t�.f+�1w D s rcr,•1.I C.
I(M R.SM ti0s Rrlf:RZMYE Cl: 9 c501
f:7t3U18l 1.2000 r,;` L4. 62,44(, -
USE OF PERMIT
C;1?Z+iF;f� %�.1. F�'ti,U).)NG
6 x'11. IY'AW,
11
23100 11
k1&nxJVfx0 COU OF, CONSTRUC370V
..RRR..MTT i+'.E'F..11MI JlbYARY
CO'N0i'RUC'!`1Gi+1 F;l 1(11.000.418-00 stpoi,00
SUPT -`)t TAL. i;=
OPERATION
1
1.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
- O
Electric Bond
Footings
Main Drain
Bond Beam
d
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
Plumbingfinal
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
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 Powder
Final
Utility Notice (Perm)