0010-017 (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
ate. o ' ' Signature of Contractor 'z;
OWNER -BUILDER DECLARATION"
I hereby affirm under penaltyof 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•prope_rty, am exclusively contractinq with kensed
contractors to construct the .project (Sec. 7044, Business & Professionals
Code).
O' I am exempt under Section` B&P.C., for thls'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 for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 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 37.00 of the Labor
Code, I shall forthwith comply with-thos ',provision / r-
D/ate:•//7 -1- Applicant r �� • /
/Warning: Failure to secure Workers' Compensation coverageJs 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 applicatonagrees 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 is 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.
Da
-e
te..'%r��
,Signature (Owner/Agent)%^`'=''
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BUILDING PERMIT PERM T#
DATE VALUATION LOTS
TRACT
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JOB SITE
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ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INEER
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C`}`a 92025
MCONDMO
CSA 92025
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(71BVU.� 5413
USE OF PERMIT
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TUIVALMON.Aff.r, INES DUE OW
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RECEIPT
DATE(
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BY �. �,,.`
li,�''�
DAT�FINN
,S
NSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _
Forms & Footings �(//fi
/ _ _
6f
Underground Ducts
Ducts
Slab Grade
Steel
( `,��� _
Return Air
Combustion Air
/
-
Roof Deck
/_ rl l
Exhaust Fans
/
O.K. to Wrap
Framing
Insulation
3 %3"/
3 ` a� T
F.A.U.
Compressor
Vents
/ J
Fireplace P.L.
Grills
/
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
_
Party Wall Firewall
Exterior Lath_
_
Drywall - Int. Lath
101 0_2�_
Final
tj-�--3 -- - — -- -
Final
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
Waste Lines
/J
f //
Electric Final
Heater
Heater Final
Water Piping
Y'
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
COMMENTS:
Final
Utility Notice (Gas)
_
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
J_ _
Sub Panels
Exterior Receptacles—�
G.F.I.
Smoke Detectors
i
Temp. Use of Power
i
Final
.Utility Notice (Perm)
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