0306-068 (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
Date r " tf 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. 70441 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 : '
O I am exempt under Section B&P.C. for this reason
Date A— ' 3 - Signature,°of Owner ..F..i b',
WORKER'S COMPENSATION DECLARATION'
I hereby affirm under pendy 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 for which this
permit .is Issued. M workers' compensation insurance carrier &,policy no.. are:
Carrier €: i .t 3; 1< SMD Policy, No. i r?:� t�vl-ft3
(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: 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 rand 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.
r''^IAAt
Signature (Owner/Agent)�t✓ a 1i r,tr• An— Date
BUILDING PERMIT PERMIT(/di •
DATEVALUATION'.LOT :. �' f TRACT.
JOB SITE r 7[Y a 1°trE^`j'�j
APN
ADDRESS -- -
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
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CONSTRUCTION: Rq� 101 0-000
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MZCHANICAL MM :{ I� :c.�l�li � Q� 91.43A
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ART 114 PUBLIC is ,ACE3
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JUN •1•g 2003
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CITY OF LA.QUINTA'... ...
.
FINANCE DEPT
i
RECEIPT
DATE
BY.
D EFIIhMdECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
t Forms 6 Footings
Ducts
_12-4.03
Slab Grade
Return Air
I Steel
InCombustion
Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
I Framing
Compressor
Insulation
—
Vents
J Fireplace P.L.
Grills
f Fireplace T.O.
Fans & Controls
k Party Wall Insulation
Condensate Lines
Party Wall Firewall
a Exterior Lath
1 D II - nt. Lath
I
r
s
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
is Set Backs
Electric Bond
E Footings
Main Drain
I Bond Beam
Approval to Cover
I
Equipment Location
t
Underground Electric
t
Underground Plbg. Test
I Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
I Waste Lines
Heater Final
iP Water Piping
Plumbing Final
I Plumbing Top Out
Equipment Enclosure
IShower Pans
O.K for Finish Plaster
J Sewer Lateral
Pool Cover
F Sewer Connection
-
Encapsulation
I' Gas Piping
I Gas Test
F Appliances
!
Final
I
Final
Utility Notice (Gas)
ELECTRIC
Temp. Power Pole
! Underground Conduit
i Rough Wiring
t Low Voltage Wiring
s Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
L APPROVALS
COMMENTS:
A� / ?/Z0,6-