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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that) 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
671203 B 1 05131/2(
Date`' -Signature of Contracto
OWNER -BUILD/ . D RATION
I hereby affirm under penalty of perj ry th t I am exemptfrom the Contractor's
License Law for the following reason:
( ) 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).
( ) 1, 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.
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 FREMONT COMP914 3 Policy No. SA50069010320
(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 aA to become subject to the
,,workers' compensation laws of California, and Kee that if I should become
subject tth wor rs' compensati provisio Section 3700 of the Labor
Code, I comply wit o r9.
Date: Applicant ��
Warni ,g: Failure to secure o Compensation coverage is unlawful and
shall subject an employ 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 Statg?Iaws relating to the building
construction, and hereby authorizrepresent ti' of this City to enter upon
the above-mentioned property�for�fisB ' iory ose§.
Signature (Owner/Agent); "` Date 40,�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (1SMo TRACT
JOB SITE
ADDRESS 52-110 DU.�iLJk IE f oumr APN _
OWNER I CONTRACTOR / DESIGNER / ENGINEER
Atd'DRER PIMCE CO"ORAMOX
44635 DLTP C.E"f014 RD
PALM D1rWRT vA
USE OF PERMIT
_W8CELLAMOT0
ANDTt} iiV' 1>ffRC.E'• CORTND AnOrl
44535 :DIEP CANYON R1-)
92261 PAIM M&MRT CA 92261
�6t7�346 322�c CL * 03031
(1) Ti3MPORARY CONSTRVC'fION TF MLER PER rA.U.P.
VALUATION
1,600.00 1.3
iSF1`Il19:lfLTKD COST O1':+ COkY&I'MTC ITOR
PF62AW 1n 1R 6iCTNl1V ARY
TEMP CONSTRUCT10N T1tA1LM 101.000-423.000 $200,00
811A. TOTAL t 0N1:rrRt7t_TI0N AND MAN CHROX
NESS PFE—PAID .FEED
RECEIPT I DATE
TOTAL PEI -W1 ERS 1)'UE NOW
FINALED
�2t3U.CK>�+
IN�F''ECTI�N RE���PD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BWLDING APPROVALS
MECHAN=L APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab 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
BLOC KWALLAP AROVALS
POOLS a SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
f�I�UMBd NG 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
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTAICAL 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: