9909-209 (RPL)`'LICENSED CONTRACTOR DECLARATION
Ipereby 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.
Licenseg# !! ' �L-fic. Class Exp. Date yy ff�
%' vl'i'Q li j
vDate b �.j- Signature of Contractor' 1V
OWNER -BUILDER DECLARATION
I hereby affirm under penalty.of perjury that I ariLexempt from the Contractor's
License Law for the following reason:
( ) I,'as,.6wner.of the property, or my employees with wages'as.their sole
compensation, will do the work, and the structure isnot 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). • .1. • ...
() I am exempt under Section B&P.C. for this reason
Date, 'Signature of Owner.
WORKER'S COMPENSATION DECLARATION • " .'''
r
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. ,
(y) 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 Policy No: -
(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-tE"the
workers' compensation laws of California, and agree that if I should become
subject Jo`the workers' compensation•provisions of Section'3700.of theLabor--
Code, I shall:forfhwith comply with those provisions". \
tpate: ` d ! p' ` Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal pe%ties'and civil fines up: to $1,00,000, in
addition to the cost of compensation, damages -as provided for in Section 3706
of the Labor Code, interest and attorney's fees. L
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 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 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
construction, and hereby authorize, representatives of this City to enter upon .
t e above-mentioned property1,for inspection purposes.
.
Signature (Owner/Agent) `` �i }� zl Date �'•
BUILDING PERMIT PERMITBp>v. • .'k.
DATE VALUATION, ,[i�i.hiaV�, _ LOT•' TRACT
JOB ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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95212 16tari`ij�i:IC SON ROJk .�
4,Il.QI.1: N c",Fo CAL 92125:3
U 112,1 KNE VALLEY- CA 142356
(7M)24-8-6045 CBL -0 4A35
USE OF PERMIT
F'OOLIWOfOR SRA
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WCAL`��",jlMI i+EEAS. 01.; C, NOW
RECEIPT
DATE
BY
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
`v—
Footings
Bond Beam
Main Drain_
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test~S
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
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:
.