0103-091 (RPL)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
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;OBusiness & Professionals
Code).
O I am exempt under SectionB&P.C., for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
�
I hereby affirm under penalty", perjury oneoof,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:
C_ airier Policy No.
19'leRT&bw'f;.MP 1149 Fly.
(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' compensatiQnjprokisions of Section 3700 of the Labor
Coder h Il to hwith comply with1�seprou�ions. ' �- �g
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 370tH
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building an�t�
for a permit subject to the conditions and restrictions set forth o hi
application...
4":
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 tc
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'nspection purposes. A;
Signature (Owner/Agent)i .� Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT. TRACT
JOB SITE
APN
ADDRESS
474`751M .
-
OWNER
CONTRACTOR./ DESIGNER / EN (NEER
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USE OF PERMIT
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A*,C7RdtNICAL Fe- —POOV 101-000.421^000
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RECEIPT
I DA_T,E f
BY1
DATE FINALED
INSPECTOR
�6.
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL 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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Footings
Bond Beam
Electric Bond
Main Drain
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
,y
Gas Piping
Gas Test
Appliances
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)
Final
COMMENTS:
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