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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 Ex . Dat
Signature of Contractors-�,
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).
O 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 permitis 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:
Cartier Policy No.
CLARE-41,T)OR 11N,413
(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 Cali Ia, and agree that if I should become
subject to the.workers' compensation 0 ovlsions of ectjgn '!01 q� e Labor
Code, I hall �grt Vjtftty emply wit hJthos ;provision /J f
ate: ZZ / `,7Ap�licant -. t ., ' t. _l Sect
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Warning, Failure to secure Workers' Compensation coverage is unlawful and
shalt subject an employer to criminal penalties and civil fines up to $100,000; in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. -
IMPORTANT Application is hereby made to the Director of'Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
&.hold harmless the City of La Quinta, its officers, agents and. employees.
2. Any permit issued as a result of this application becomes null 'and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above
correct. I agree to comply,with ail�City, and State laws relating
construction, and hereby` authorize representdWe of this City
n / / a
information is
to the building
to enter upon
the above-mentioned property for `spectlon yrpo�e . �r /
ignature (Owner/Agent) -� ^ r DateA l
BUILDING PERMIT PERMITp
DATE / 4 VALUATION LOT TRACT
JOB SITE
ADDRESS S:!-C4O« �I. �i�t 9$�$.b1'� C154:~LH
OWNER
CONTRACTOR) DESIGNER / ENGINEER
ALPA HARDER
BUJE HAVEN
� fD:S 1)� 1rRfiRCY:i4'+i C i9 �:':I.as
2,3iS S. VINEYARD AVENUF,, SUITE A
LA QUQA - 9. ("A1 ±i'L7..53
ONTARIO i4'A, 017ni
r,Y '9Ai-t4�l 14 C''Ri dj 57 -iii
USE OF PERMIT
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PI JV,1 CHECK 1.11, JW -M) -439-31e 4152.10
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WIECIMCIALFLAi BOOL. tiiiI ,f, 550
Pf.1.114i➢.040.(1ltl, pa YA,
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TOTA1, PEIti 11T FUeN 011.. NOW
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RECEIPT
DATE
BY r
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHAMCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
L$ LOCKWALL APPROVALS
POOLS e SPAS
Steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
..le{ —60 [
PLUMMMIG 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
Z- -L'R,
Gas Piping
Gas Test
Appliances
Final
Z - Z
Final
Utility Notice (Gas)
GLECTi MCAL 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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