0307-098 (SFD)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
Professionals Code, and my License is in full force and effect.
License # Lic. Class �' Exp. Date
t. rfj i t. f r
Date $ Signature of 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_ r 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 maintan`a certificate of consent to self -insure for. workers'
compensation, as provided forlby 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 T a f.j':�i.. IAiDt:7',} }�. Policy No.
(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 intany manner.,
anner so as to become subject to the
workers' compensation laws of^California, and agree that if I should become
subject'to the workers' compensation,provisio�ns of Section 3700 of the Labor
Code { I shall forthwith comply with those provbsions—..,,,• ,
pate: i Applioant °
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
application.
1. Each person upon whose behalf this application is made & each person at i.
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 It
.work, is not commenced within 180 days from date of Issuance of suchn
permit; or cessation, of work for 180 days will subject permlt.to cancellation..
I certify that I have read this application and state that the above information•is.
correct. I agree to comply with all Cityrand State laws relating to the building-,
construction, and hereby authorize representatives of this City to enter. upon
the above-mentioned prope rty for Inspection p!rposes�
Signature='wnr/Agent), It,a� R 1 y, �owF D
(ate
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BUILDINGAr PERMIT.: PERMITa''�n u
DATE VALUATION D;d,Q„9g:.{l; LOT TRACTt%;?
JOB SITEMIDAPN�
ADDRESS - - -
OWNER
CONTRACTOR/DESIGNER/EN INFER
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JUL. 2
CITY OF LA•QU1. :.
FINANCE
Cs1=FST
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RECEIPT'DATE'
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IN ORJJ
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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
2
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath[Jr
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment:Location•--
—_-
L16derground 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
'Pool Cover
Sewer Connection
s
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 a
Temp. Use of Power.
Final
Utility Notice (Perm)
COMMENTS: