0302-022 (RPL)6ICENSED 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 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).
( )Xi, 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
Bate 1 Signature of Owner
f -) ^ry/,;; f!t 4 . • '
WORKER'S COMPENSATION DECLARATION a
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 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: f a u 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 $100;000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. '
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth. on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued -as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Sigfiature (Owner/Agent) - Date 7' ,
t 'E"JILDING PERMIT PERMIT# :.•�`
DATE ` - r VALUATION LOTS-� TRACT
JOB SITE +rtr
ADDRESS2-ji�a%k>
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
R3W 19, ,.x.,iKAN
0,14W114 - BURDYA
-52-9075 Aii1*VY.DA VT1.Lk
USE OF PERMIT
POMIAMIIOR VIP.& =
,P+C704LSP AE A aJiiJ1 i$i�:12 i ). ; i$l; ilii j;P �4{ Fyl�L'$' �f3�ir►'a./4Li�`l�I
i<'!" OL Alv"IXYR SPA NAOMI 14
' MIM41,343) COU OF C ON1, "41Mt.Ir(ON
'PL&14 C,H..WY. W. 101-000-439-318 2�ib,ft5
.O.A�Sx tbC'ttDi fEP,G0
30NEM1MICAL}VE.P._'
"�10
, ?01--00 -42q
POW, SB'6e�
EL-EfsTrItc,A), r9li, .. POOf., ES.t70
Pi,:i3M1 YHO FEE • P00,11 A 01.000,4194)00
Li.P,�*F11TCtIEt1fii):t'I,tw('HEC1C
$289.115,
.f -IRE FXJ)Vi 3.0
$'0.00
TIt�a�rl►a� ��:S MIX NOW
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RECEIPT
DATE
BY ,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
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
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
(LVater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Se+nrer Lateral
Pool Cover
S �-wer Connection
Gas Piping
Encapsulation
Gas Test
;apliances
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:
CITY OF
LA QUANTA SUB -CONTRACTOR LIST
'
JOB ADDRESS Sa ' 975 aae•
PERMIT NUMBER
�_ OWNER BUILDER
A
This form shall be posted on the job -with the'BuilcTing
Inspection Card at all times in a conspicuous place. •Only persons appearing on this list or their employees.are authorize
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in,a stoppage of. work and/or the i
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•
of building permit. For each applicable trade, all information requested below must be compl'eted
by applicant. "On -File'" is not an acceptable response.
_.
Trade . Cla sift :....:
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:.,..:State::Contractor sLicense :.•: :: ...
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_: ; Workers;:Gompe�saU..o.�;;l.nsurance
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Company Nam_ a
Classification
License Number
Exp.
Date
Carrier Name
Policy Number'
Exp. Date'
License Number
Exp. Date
'
(e.g. A, B, C-8)
(xxxxzx)
(xx/xx/xx)
(e.g. State Fund, CalComp)
(Format Varies)
(xx/xx/xx)
(xxxx)
(xx/xx/xx)
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