9908-196 (BLCK)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 Exp. Date
ell—
yDate. Signature of Contrac of � rl
kQ
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 forworkers;
compensation, 'as- provided .for. by .Section- 3700 of the Labor.' Code,;for ,the
performance of "the work for which this permit is issued.
(� I have and will maintain workers' compensation insurance, as required by
Section 3700 of. the Labor Code, for the 'perfo.rmance of the work for "which this
permit is issued. My workers' compensation insurance carrier &' policy no are:
Cartier Policy No. ' `^
(This section need not.be completed if the permit valuation is for $100.00 or less):
O I certify that in the performanceof the work•for.which this,;permit-is issued,
I shall not employ any person in any manner so as to become subject,to the
worker compensation laws of California, and agree that, if I should become
subject to the workers' compensation provisions` of Section' 37K.of the Labor
C e I
all to ' w.i�h comply with ose p(visions. /r
ICate: 1 Applicant r
Warning: Failure to secure Workers' Compe�ation coverage •is unlawful Al
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation,• damages a's 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
fora permit subject . to the conditions .and rdstrictions 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,.indem.nify
&. 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.,11"agree to comply with all City, and State laws relating to the building
constr ktion, and hereby 'authorize representatives of this City to enter upon
the,above-mentioned property for inspectiorrpurpos S.
-25
�
'Signature (Owner/, ent Date
a BUILDING PERMIT PERMITk
DATE VALUATION LOT TRACT 71JOB
SITE,
ADDRESS 74.482 LN 5,�N ',
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APN
.ROCK:
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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y,�,�r�.>rf"n (`"•rR'�r9�} vr!(^�t��C"���a�'r,•ti'���.i�
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'A)VINIA 7410S
PALIMDII:SEXT ' . *w:;r>s. 92260
.OK
f ff")U} 141 ' CBL - 4554
t 9
USE OF PERMIT
OT, ".8.PTED •1„eNtlYle:•. ��1•7.4�Y!3,f.§'k})CT-1.F.i.;`
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CHECK
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PAID FE
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RECEIPT
DATE
BY (
D�INAL.E �
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
_
Footings 6 2— 7
Main Drain
Bond Beam
Approval to Cover
'C, 7'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)