0304-250 (SFD)_
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LICENSED CONTRACTOR DECLARATION
PERMIT#
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I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter Section 7000) Division 3 the Business
BUILDING PERMIT
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9 (commencing with of of and
DATE VALUATION g +a l' ^<' I
3i .&9, T�. �� LOT C�i TRACT. 30071✓
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Professionals Code, and my License is in full force and effect. _
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License # Lic. Class Exp. Date
JOB SITE
ADDRESS Y 1�1�- a 1 a.=:.c %
APN '764 470rt0E`A4
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OWNER
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CONTRACTOR/DESIGNER/EN (NEER
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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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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
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contractors to construct the project (Sec. 7044, Business & Professionals
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Code).
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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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O 1 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
is issued. My insurance &
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permit workers' compensation carrier policy no. are:
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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 become subject to the
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workers' compensation laws of California, and agree that if I should become
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subject to the workers' compensation provisions of Section 3700 of the Labor
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Code,l shall forthwith comply with those provisions�,,.....w�.. _�
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Dat"e.
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S iR.O+aCI MOTION F ME> ",01Pl ti.l EJCQ-241.000 ux"1.
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Warning: Failure to secure Workers' Compensation coverageis unlawful andW
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shall subject an employer to criminal penalties and civil fines up to $100,000, in
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addition to the cost of compensation, damages as provided for in Section 3706.Itl'
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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
application.,;
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
& 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
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work is not commenced within 180 days from date of issuance of such
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permit, or cessation of work for 180 days will subject permit to cancellation.
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I certify that I have read this application and state that the above information is
'CIN OF LA QUINTA"
FINANCE DEPT
correct. I•agree to comply with all City, andState laws relating to -the building
hereby authorize representatives of this City to enter upon
construction, and
the above-mentioned property „for"inspection�purposes. 1 tri
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RECEIPT
DATE
BY
DFI D�pf3
INSP
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Date
,,,:,Signature
(Owner/Agdnt)�
INSPECTION RECORD
OPERATION
DATE
I 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
_ 2/—ate 15
F.A.U.
Framing
_ 310 --0 3 Com'
Compressor
Insulation
— 0
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
p — —
Drywall - Int. Lath
16 09 AA
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
p
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
71,
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) j