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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under prb4isions 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
x4 D 3 4
-Date {1 Signature of Contractor-
. k, - - -
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 (Seca 7044, Business & Professionals
Code). ,� w
() 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.
SecI have and will maintain workers' compensation insurance, as required by
tion 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 NAT4f,ytIAii UN1104 Z' Policy No. 7085,%9 ' .
(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 employanyperson in any manner so as�ttolIbecome subject to the
workers' compensation laws of Califc6a, and agree that if I should become
subject to the workers" compensation-pr;vvisions,,o f Section 3700 of the Labor
Code;, I shall forthwith comDly withhhose Drovlslons.�--~�^
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 applicatornagrees to, & shall, indemnify;
& hold -;harmless the City of La Quinta, its officers, agents and employees
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2.'Any permit issued as a result of this application becomes null and void if
work" is not commenced within .1.80 days from date of issuance of such6
permit, or cessation of work for'180 days will subject permit to cancellation
1 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 tf e'building
construction, and hereby'sauthonze representatives of this Citi -to enter upon
the above mentioned property, for inspection purposes. s
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.Signature (Owner/Ant) ��f Date
-
,,,Signature
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BUILDING PERMIT
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" DATE •• VALUATION .�.z,� LOT wy TRACT jf�ary�:9'
" JOB SITE
;ADDRESS :` �Xi`..Wi?i� �a'o
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OWNER
CONTRACTOR / DESIGNER / EN (NEER
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LA QUigrA C4 92833
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$4,01 tli.68
JUN 2 6 2003
R` fEAL' s EY ]YETS, DXTY NOW
CITY OF LA QUINTA .
FINANCE DEPP
RECEIPT
DATE
3
BY
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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 Q—
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 I
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 APPROVALS
Gas Test
Electric Final
Waste LinesHeater
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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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