0303-044 (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
'Profe'ssional`s Code, and my License is in full force and effect.
License # Lic. Class Exp. Date j
fD_ate t Signaturef 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:
( ) 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 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 NATIONAL U1141014 Y Policy No. i011�3ftS1
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 1Secti6n '3700L'of the Labor
Code I shall forthwith comply with rovi§i
thoslons. I �!
App`ccant� .11
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„cry
application.
1. Each person upon whose behalf this application is made & each person. at il
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
& 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 rep-resentatives of this City to enter upon
the above-mentioned property,.for insp6cction"pur'poses,00
Signature (O,nec%Agent)1 R '*•^° �ate���
BUILDING PERMIT PERMIT
TRACT
DATE VALUATION LOT TRACT
(k 11 T4s C �+J "1.09
JOB SITE
ADDRESS >'Y�to,A%�
APN
_
OWNER
CONTRACTOR/DESIGNER/EN INFER
SEM,t.,4 i°1 r1
9111—R& ffowd a
81-.260 AVENIN? 62
.91 -260 AVENUE 62
`1 Wags
T-i:fl.�MAn. CA 92583
(smg 143n-8996 I C,.F;'1.,.�# 6876
USE OF PERMIT
13't LF of & OL D:EN WALL 0IC,C0 '.i`I'AND..ARD
6 FT. WAUL 1 Lr
PMWr Fal SUMMARY
C0 STRAir,T1014 PM 101,000.418.000
' •IbY�
014 AM
t,��yt�.�l�ryCHECK
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MAP114 s�� �k>.T TE now�.
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CITY or LA 09d[PYtiA
FINANCE DEPT.
`RECEIPT
DATE/ `
ABY— Y'
DATEFOALED
`I
INSPECTOy/
a�
i
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines '
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs_
Electric Bond
Footings _
Main Drain
_
Bond Beam �3 I
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
PLUMBING XPPROVALS
Gas T
Elect c 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
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)
COMMENTS:
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