9705-041 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under of that I licensed under of
BUILDING PERMIT PERMIT# CONTROL# `�
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penalty perjury am provisions
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Chapter 9 (commencing with Section 7000) of'Division 3 of the Business and
Professionals
DATE (! T�/ VALUATION LOT f TRACT
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Code, and my License is in full force and effect.
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License # Lic. Class 6p—Date
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JOB SITE
ADDRESS '�O'�•�JNNIA�l�..t�ii�.�"jjA,
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OWNER
CONTRACTOR/DESIGNER/ENGINEER
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''' � Signature of Contractor
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OWNER -BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's ;
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i' 293 RANCHO LA GUiN A DR.
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License Law for the following reason:
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( )' I, as owner of the property, or my employees with wages as their sole
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compensation, will do the work, and the structure is not intended or offered for
USE OF PERMIT
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 & Professionalsi
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Code).
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O I am exempt under Section , B&P.C. for'this reason
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Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
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() I have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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() I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
insurance &
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permit is issued. My workers' compensation carrier policy no. are:
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Carrier Policy No.
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'ESTIIbSS�':fFDI�t�S'� Or( C:O'l�S"TRUi`,�iON'
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(This section need not be completed if the permit valuation is for $100.00 or less).
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( ) I certify that in the performance of the work for which this permit is issued,
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I shall not employ any person in any manner so as to be oc me subject to the
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workers' compensation laws of California, and agree that if 1- should become
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Subject to the workers' compensationp'rovisions,o Section 3700 of the Labor
Code, I-sha(forthwith comply with those/provisions.
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Date: Applicant +
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Warning: Failure to secure Workers' C rnpemsa ion coverage is unlawf l and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
(lit AMU FEE $20.00
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addition to the cost of compensation, damages as provided for in Section 3706
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of the Labor Code, interest and attorney's fees.
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IMPORTANT Application is hereby made to the Director of Building and Safety
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for a permit subject to the conditions and restrictions set forth on his
fes•
application.
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1. Each person upon whose behalf this application is made & each person at
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whose request and for whose benefit work is performed under or pursuant to
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any permit issued as a result of this applicaton agrees to, & shall, indemnify
ISIJIB-T'n1;A1, CONSTRUCTION AN 0 MAN t.RECK
$5,919,67
& hold harmless the City of La Quinta, its officers, agents and employees.
1, LOSS PIUM)AID FEES
$000
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'd1TAI, PERMIT I (t 1K,E+N 0111E NOW
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I certify that I have read this application and state that the above information is
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correct. I agree to comply with all City, and State laws relating to the building
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c • nstruction, and hereby authorize representatives of this City to enter upon
e above-mentioned property for inspecUon�Urposes.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Date
Signature (Owner/Agent)•✓ ` ';?
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs l G
Underground Ducts
Forms & Footings
Ducts
Slab Grade
(,{C
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap -
Ll
F.A.U.
Framing - -
L L
Compressor
Insulation Yj-
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
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
OX for Finish Plaster
Sewer Lateral r
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test -/0
Appliances
Final ..
COMMENTS:
Final
Utility Notice (Gas) -
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)