0306-198 (BLCK)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 # Licp. Class Exp. Date pp
Date `-•' % ' ' t' '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 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.
•( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work f& which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier k3l 7E V0N"ID 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 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 those provisions.
Date: + , Applicant—
Warning:
pplicant 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
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 for inspection purposes.
Signature (Owner/Agent) f -tri^"" --�- Date �' 9 •'�"j
BUIL- DING PERMIT PERMIT
DATE4�43i�4� VALUATION''` (pa} LOT TRACT
JOB SITE `; A;_02 7 W' DROYD 1 0T
APN _ ..
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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USE OF PERMIT
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FINANCE -l), -PT
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%1 00
TOTAL IYUR NOW
RECEIPT
DATE
BY
PATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I DATE I INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
0. K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
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
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
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures 7 -
Main Service
Sub Panels
Exterior Receptacles _
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice (Perm)
-_ s ----CITY F LA'QUIN�TA
BUIL• DING: & SAFETY DEPARTMENT
R.�
ILS. �. INSPECTION REQUEST LINE
CITY OF ua QILN'lA I
77-7153
FINANCE DEBT. j ` r
Owner 'TES R A VF Q, ks'
Contractor ,W n007
Permit Number 0306-19'3
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN'ALL APPLICABLE SPACES
'JOB ADDRESS 56-027 WINGED FOOT
14 L.F. 4' GARDEN WALL, CITY STANDARD
t
TYPE OF INSPECTION DATE ANSP.-'
TEMPORARY POWER
SETBACKS
U/G PLUMBING/ WASTE
U/G ELECTRICAL/ GROUNDING
FOOTINGS / STEEL.
CONCRETE SLAB
DO NOT POUR CONCRETE UNTIL ABOVE SIGNED
ROOF NAIL / PRE -ROOF
OKAY TO WRAP .
RAMING COMBINATION
ROUGH ELECTRIC
ROUGH PLUMBING r
ROUGH MECHANICAL
INSULATION
COVER NO WORK UNTIL ABOVE SIGNED
INTERIOR GYP. BD. (DRYWALL) -
EXTERIOR LATH i
GAS TEST '
SEPTIC ABANDONMENT
';'SEWER CONNECTION --� SEPTIC/ GREASE INTERCEPTOR
'MASONRY INSPECTIONS
FOOTINGS / STEEL p3 G
BOND BEAM Q 3 —�
POOL/ SPA/ WATER FEATURE INSPECTIONS
PRE-GUNITE / SETBACKS
U/G PLUMBING
U/G GAS 5i
U/G ELECTRICAL'
PRE -PLASTER ALARMS / BARRIERS
FINAL INSPECTIONS
TEMP.'USE OF PERMANENT POWER
ELECTRICAL
PLUMBING
MECHANICAL
PUBLIC WORKS DEPARTMENT
COMMUNITY DEVELOPMENT DEPT I'
FINAL / JOB COMPLETED/"g
ABOVE APPROVALS DO NOT, INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING