0102-143 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04W Professionals Code, and my License is in full force and effect.
E = M ' License # Lic. Class Exp. Date
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ZO r-- e Signature of Contractor�4..,�� ��i� -a►
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OWNER-BUILDER DECLARATION $'
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 1, 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).
C') () I am exempt under Section , B&P.C. for this reason
LID
N Date Signature of Owner
ON
Z WORKER'S COMPENSATION DECLARATION
o rr, I hereby affirm under penalty of perjury one of the following declarations:
LO H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X LU IL compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q O ) I have and will maintain workers' compensation insurance, as required by
O U QSedtion 3700 of the Labor Code, for the performance of the work for which this
rn permit is issued. My workers' compensation insurance carrier & policy no. are:
`t z Carrier Policy No.
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Q (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 these p�pvisions
D'Ae: rf -p) r' ApplieantY
4 Warning: Failure to secure Workers Compensgfion 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
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
& 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, inspection purposes.
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Signature (Owner/Agent), �' !` 1 Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT�i%�,i
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JOB SITE
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ADDRESS
11111-919 71FROaf AVA
OWNER.
CONTRACTOR / DESIGNER / ENGINEER
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CA 51'2408
PAi.IA UFCA 92260
USE OF PERMIT
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs
Forms & Fcat{ngs
Slab Grade
Steel
Roof Deck
O.1<. to Wrap
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Water Piping
Framing
Insulatich
Compressor
Vents
Plumbing Top Out
Equipment Enclosure
Fireplace P L
Grills
O.K. for Finish Plaster
Fireplace T.O.
Fans & Controls
Appllar les
Final
COMMENTS:
Party Wall Insulation
Condensate Lines
Final
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
p(`)C)l S a IgPAR �
Set Backs
Footings
gond Beam
Final
BLOCKW-'ALL APPROVALS
PLUMPEh'4G J1,PPROVAL,S
Steel
Electric Bond
Main Drain
Approval to Cover _
Equipment Location
Underground Electric `
Underground Plbg. Test
Gas Piping
Gas Test_
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sircv,er Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_ Gas Piping
Gas Test
Pool Cover
Enoa.psulation J
Appllar les
Final
COMMENTS:
Final
Utility Notice (Gas)