0306-487 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that l 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 # J yyL�ic. Class Exp. Date s
t o�
Date = ! v Signature of Contractor / C_,7 ---
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1;'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 Cade).
(.) 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 selMnsure 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 STATE FUND , Policy No. M362.4_0.
(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 with those provisions. t
,Date: tf- r - Applicant "x• ,°..�
Warning: Failuretosecure 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 compelnsation, 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 D
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 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 property for inspection purposes.
r Signature (Owner/Agent) �: 'fes '"_'� . . Date
BUILDING PERMIT PERMIT�y���
DATE VALUATION $I LOT 'r TRACT 29", 23 --1
ADDRESS 43 54JOB SITE 1, Peik4,i',T0WA.`!k , .ti:P' .gL�ht % ; a�i` its
APN
SfY.�` 80-Co13
.OWNER
CONTRACTOR / DESIGNER / EN (NEER
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TOTAL N—M&T FKVN DUE MW
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CITY OF LA QUINTA
FINANCE DEPT.'
RECEIPT
DATE
BYDA
IN
INSPECT
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 .100
O.K. to Wrap
F.A.U. ol
Framing
Compressor
Insulation
✓
Vents
Fireplace P.L.
Grills 2 pe
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
YIN
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
MPROVAL
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
i
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 51
Low Voltage Wiring
Fixtures
Main Service 100,
Sub Panels ol-
Exterior Receptacles
ot
G.F.I. 110
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) zd