9910-144 (SFD)LICENSED` CONTRACTOR DECLARATION:
I. hereby affirm under penalty of perjury that I am licensed under provision`s 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 # Lia Class ,Exp: Date.
,Date « ley r Signature of`Contractor
OWNER-BUILDER`DECLARATION' "
I hereby affirm under penalty of perjury that l am exempt from the Contractor's
License Law for the following reason:
( ).. -1, as owner of .the: property,- or Imyemployees, with wages as'their sole
compensation,,will do the.work, and the structure is not intended orIoffered-for
Sale (Sec. 7044,.Business & Professionals Code).
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:
() (.•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,.ft
performance of the work for which this permit.is issued:.
(') 'I have and will maintain workers' compensation 1nsurance, as•required by
Section 3700 of the Labor Code, 'for the performance of the work'for:which this
pernhit 'is issued. My Workers"6ompensation' insurance carrier.;& policy" no: are:
Carrier Policy No.
NIS: {`' VIPAINY'OF T' 't1i`t3amw 1
(This Section need not be completed'if the.permit valuation is for $100.00 or,less).
O I certify that.in the performance of.the work for which .this'permit is issued,
('shall not employ any person in any, manner so as to'become.subject°to.the
workers' compensation laws of California, -and agree that if 1. should.'become
subject to the workers' compensation provisions oi5dction 3700 of the Labor
Code, I shalkforthwith comply with"th'oseprovlsion's. �
ate: " '`:/'-`:/fi�,WAPPlicant . ,
Warning: Failure to, secure Workers' Compensation coverage is unlawfulr and
shall subject an employer to:criminal:penalties and clvll'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'afforney's fees.•'
IMPORTANT Application is hereby made to the Direcfoe of Building and'Safety
for. a, permit sto
ubject ' 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.
nder 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
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 Vhave 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 fo'r inspection purposes.- '
VSlg" nature (Owner/Agent). ! ��'r Date
PERMIT# `-
BUILDING PERMIT.,
DATE TION �v 3�9q fO.JV LOT'y287-97V,ALIJj ,
JOB SITE
ADDRESS= �3�- �'Pp40iael f. a
APN l�-`DSIiY iy>iP
I
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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ss 77 ,,trrr 11nn PPyyr� ll yy
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425.
L,A.QIJIMA CA °a ZT�
PHOFC M!'.K . •'AZ. $504
.499.1
USE OF PERMIT
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RECEIPT,
DATE
1'BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/-2 -
Underground Ducts
Forms & Footings
�/L�_ !
Ducts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck
_cef
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Z: — G(/
Compressor
q ��
Insulation
�� aU
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
2,nlk W
Final
Final
-
POOLS - SPAS
BLOCKWALL 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
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 Power
Final
Utility Notice (Perm)
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