0208-033 (RPL)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 t\ Exp. Date
Date Signature of Contracts "- l
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
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.
4(�) 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 STATZ pMQ) Policy No. 229.01-0001.334
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that inwthe performance of the work for which this permit is issued,
I shall not employ any person in any(manner so sato become subject to the
workers' compensation laws of California, and4agree,,that if I should become
subject to tfie workers' compensation, revisions of -§S ction 3700 of the Labor
Code, I shall forthwith comply with those:;provisions.
` Appll a t"' 'r �`-4
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 pursuant to
any permit issued as a result of this applicator 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 enteryupon
the above-mentioned property for irispection purposes. ' ,(
,,-Signature (Owner/Agent)f '°ry 'b �`� Date
BUILDING -PERMIT PERMIT#
DATE VALUATION LOT TRACT
147
JOB SITE
ADDRESS 47-14-5 V.A MMED nt
APN
..
OWNER
CONTRACTOR/DESIGNER/EN INFER .
CARADAY &, COMPANY
ELM, 14AW ON dbu VACAnOM P30W1
17480 X 171.111 0M. #106
55:2,2 Dk.) ALD9-; 24 RD,
Iia W 92780
LU'0TRWT.VAL1ZT CA 92356
(➢G0)24fS.6t4.5 CK4 4333
USE OF PERMIT
POOL AWWOR SPA c
POOt fs'PA,..a LARMSt8r'.! J11sks smAA L BE Fid PLACE PRIOR. TO
PU—PL ASTE t 1.->^8'SPECTI014
POOL AA+FDJOR SPA
COST OF COMSMUOMON
I510mir
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.IG 1¢J.Sd[Y.Y.2. A.&a ' w ivrJ,►v6a7�Lyi,'�. 1C
PLAN CHECK FZIr
CONS'I'1 UCT1014 FEE Yp?-a�iii-�9t3�CiU0 �ta1,Ov
MECHANICALZ... T?(L 101»004-2,1,-0M,
ZTRAIAL}J:— TOUL -004,2.0-000
P'L;umolAi027.00
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CITYOFWQUINT/!
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TOTAL Pk'R_kW YXE3 DUE ROW
W6 3.30
RECEIPT
DATE.
BY�,
D E 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
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test _
Electric Final T
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 y
$�
Gas Piping
Gas Test
Appliances
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)
Final
COMMENTS: