0204-039 (SFD) (2)LICENSED CONTRACTOR DECLARATION f
L,hereby affirm under penalty of perjury that I am licensed under provis'�.�...Af
C,haptdr 9 (commencing with Section 7000) of Division 3 of the Bush -S lard
Professionals Code, and my License is in full force and effect.
I..,�License # Lic. Class Exp. Date
Date Signature of Contractor
'- OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( d,,.,.=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).
( a),.- 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 1f..n �„ .� 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.
( ) 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.
(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
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply withthose provisions. �r
Date: % Applicant +• fi r -•j /
Warning: Failure to secure Workers' Compensation coverage is0Unlawful 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 i
& 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 propertyJor inspection purposes.
r.
Signature (Owner/Agent) `"��° -- -- Date �.•/T•/�'.=1
_ BUILDING PERMIT J` f' -
DATE VALUATION aK LOT TRACT Yy r
JOB SITEryKpq��1.
ADDRESS'C3VSA.ise 0
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER,
DEMSE 0.00DUA N
OWNER BUILDER
DER
LA QU.VJ VA- GA, 92253
USE OF PERMIT
3FT) - P:fMMIT rj= NOT MC;LUD9 MOCK OCK WALL, POOL, Olt DP.PJ'i+.WA.Y'
APPRf.)ACj'•r 08 C.01)E.
TRACT CONSTRUCTION' SF
FE,39iGD (FATIO 126.00 S1r
aA...r ORCARPORT r� ao sr
3b
150AIR91,80
rmw b n ai3� mwy
CONS'PI1.i1CTION Tom- 101.000-418-000
PLAN CHECK WE 101-000.4 30� -i 1 tR $6100 33
E DEPOSIT 101.000.439.318 4250100
MW31ANICAL FRE 101-000-421..000 $109.00
W-01 RICA1, M, 101.000.420-000 $150-40
PL.UM131W0 MIF 101 -000-419-M II1SL 50
S`i'RONG MOT TOW FRIX RPSID 101-000.241.000'
UltAY)MIC FEi<' 101-000-423.000 �tlt.f)D
T:3EVA- oO.PER IMPA.CT k`4ti.E
i
IMTB-TM A1.) C. y UTIC T°It.'1N AiD:) Pl J' C REEK
s -?-,857.1 S
LESS F1RF-P %TD FEEZ
4250.00
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RECEIPT
ATE
B� P
DA E FIN D ^ !/
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 U
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final _
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
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
Seger 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)