0106-138 (BLCK)_ LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C aptero.( 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' c
I hereby.affirm under penalty of perjury that I am exempt from the Contractors
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.,
( ) I, as owner of the property, am exclusively contracting with licensed
contractors,to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt t under Section B&P. r. oi°thisprerason �...f
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
(,) 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�s'all not employ any person in any manner so as to become subject to the
Workers' compensation laws of California, and agree` at if I should become
subject to the workers' compensati?pprovisions of Section 3700 of the Labor
Code, I shallorthwith comply with those pro r
Applicant
VWarning: 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 -Y
for a permit subject •to the conditions and restrictions set forth on his
application.
1. Each,per'son 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 reg'r`es nta 'ves of this City to enter upon
the above-mentioned prope'Ry for inspec in pal oses.
y � )
Signature (Owner/Agent) bate
BUILDING PERMITPERM T#
DATE _VALUATION LOT •> �•b� TRACT.- = f
JOB SITE APN
ADDRESS'14 M45 AVEMMA
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'OWNER I CONTRACTOR / DESIGNER / EN (NEER
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BY I DATE FINALED I INSPECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
j 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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
l
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAL
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping j
Plumbing Final
Plumbing Top Out i
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
'Sub Panels
' Exterior Receptacles
G. A.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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