0203-093 (BLCK);LICENSED CONTRACTOR DECLARATION
I hereby,,affirm'underpenalty ofperjury;that l.am licensed_ under provisions of
'..Chapter 9 (commencing.with
Section ,7000) of Division'3 of the�Business and
-Professsionais_ Code, avid my Lic
-
C.
ense is in full force and effect:
r6d_n e # LiClass Exp. Date ,
Date Signature of Contractor ,
OWNER -BUILDER DECLARATION
• k
I hereby affirm under penalty of perjury. that 1'6m exempt from 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).
( ) _I, as owner of the property, am exclusively contracting with liggAsed
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 wofker�
compensation,. as provided fof by Section 3700 of the Labor Code, foVe
performance of the work for which this permit is issued.
p) I have and will maintain workers' compensation insurance, as required by
Section 3700of the Labor Code, for the performance of the work for which this
permit is issued. My workers', compensation insurance carrier & policy no. are:
Carrier ST/3,'!E,,FYfNP. Policy No. UW13t
(This section need not be completed if the permit valuation is for $100.00 or less).
(• )'1 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 provision& of Section 3700 of the Labor
Code',_1 shall forthwith'comply with those provisions..
Date:, "Z r'. , . + 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 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.
'Ir
Signature (Owner/Agent) -' �� Date
PERMIT#'
-� BUILDING PERMITk;..a,;'..,Tr
^AION_FTRACTDATE VALU
47,
JOB SITE
ADDRESS 47- W WAS9HMOTO 91 EW,
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OWNER
CONTRACTOR / DESIGNER / ENGINEER 6 r
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(7611)346.0.70 . MR 6541
USE OF PERMIT
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RECEIPT
DATE
o
BY
DATE F ALEP
INSP R
r t.
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
S& 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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
- /. _p
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
Gas Piping
PLUMBING APPROVA S
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Seet,er Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL 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: