0208-268 (BLDG)LICENSED CONTRACTOR DECLARATION
U) 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
04 L2 Professionals Code, and my License is in full force and effect.
CV) License # Lic. Class Exp. Date
LID3/1�`?)103
LLJ V- : . 7 3 3 1. 5 2 . BHK,'
Z r- /Date /26jb�§ignature of Contractor
_J
(D C) 0
r- I.- CID C) OWNER -BUILDER DECLARATION
LU w I hereby affirm under penalty of perjury that I am exempt from the Contractor's
F- a.
License Law for the following reason:
Z. ( ) 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). 17
cr) I am exempt under Section B&P.C. foil this reason
ur)
O C\I
cli Date Signature of OwneA.
0)
< WORKER'S COMPENSATION DECLARATION
N1, Z
C) I= CC I hereby affirm under penalty of perjury one of the following declarations:
Lo
— F<- 0 1 have and will maintain a certificate of consent to self -insure for workers'
X LLj Y= - compensation, as provided for by Section 3700 of the Labor Code, for the
0 _J _J performance of the work for which this permit is issued.
co _J <
< I have and will maintain workers' compensation insurance, as required by
C5 0 SeQi6n 3700 of the Labor Code, for the performance of the work for which this
U-)
0) permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Cartier cTATJE F1314f) Policy No. 9MIVINYT0009_05
ob 5
r- 0
< (This section need not be completed if the permit valuation is for $100.00 or less).
_J 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 shoyld became
subject to the workers' compensation provisions of Section 3700 of the Labor
shalt
)f�rth�!
h comply with those iovi sions.
Date Applicant—
Warning: Failure to secure Work . ers' Compensation coverage is unlawful and
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 37,10
i
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and SafFt
for a permit subject to the conditions and restrictions set forth on
application.
1. Each person upon whose behalf this application is made & each personis
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 {his 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
construction, and hereby authorize representatives of this ity to enter upon
I
the above-mentioned property for inspection purposes.
1&gnature (Owner/Agent)
Date
BUILDING PERMITPERMIT. #
012M
DATE VALUATION LOT TRACT
JOB 9ITE
AP
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INEER
zJ_K,)Xh 1064)
A. QUINTA
C'MRI)IFF BYDFIESEA. CA 92007
'45 721 1 'PaD
C160)6, .,1010
USE OF PERMIT
ESUMA'ED Ole (.1101161RUCTIM
RKWAIT VIM'SUMMARY
01
'MROAG 1V1o,noi4 MKS - RIF�-A-101 -000-241 -000 $1.00
"IN
ov
FINANCE01EPT.
RECEIPT
I DATE
BY
S7
DATE FZIYAL
IN CTO
I
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 Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
_
Drywall - Int. Lath
Final oll
Final
POOLS - SPAS
BLOC KWACC 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 _
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
' Sewer Connection,
Encapsulation
Gas Piping
Gas Test
+ Appliances
Final
4 - ----- —4
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Raag`, Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)