9911-050 (BLCK)' LICENSED CONTRACTOR DECLARATION
;, 1 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
.P�ofessionals Code, and my License is in full force and effect.
License # + Lic; Class Exp. Date
C10CM& 10 (X
Date/Z'r—e � Signature of Contractok
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 fFie Labor'Code, for. the
performance d.
ormance of the work for which this permit is issue
(:) 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.
STATE FIJND 4,12420
(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
workrersrcompensation laws of California, and agree that if I should become
�su Iect to the workers' compensation provisions of Section 3700 of the, Labor
de, I shall forthwith comply With th0 e'pro isio S� k
"Date: Applicant%
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 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
the above-mentioned property for inspec ion purposes.
♦' ,�•• ,may
49ignature (Owner/Agent"' * '` Date
BUILDING PERMIT PERMITN
DATE/4VALUATION[�{`1 LOT TRACT
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OWNER
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INDIO
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USE OF PERMIT
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LESS PR'?41A1V FEE.^
X(119
14'4;k i -L �°EMMIT VV, V-3 ipU91 NOW
RECEIPT
DATE
BY '` ^`
DATE FINALED
INSPECTOR
17 -s 3
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.Q.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali 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
Gas Piping
PLUMBING AP ROVALS
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: