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LICENSED CONTRACTOR DECLARATION
10
er penalty of perjury that I am licensed under provisions of
Chapter nim cing with Section 7000)'of Division 3 of the Business and
Professionals Code, and my of
is in full
force and effect.
License # Lic. Class Exp. Date
L4X1,12;;
/ale G' I1'_eN1Signature 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, Business & Professionals
Code).
( ) 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 workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
11�) I have and will maintain workers' compensation insurance, as required by
S n 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:
Cartier 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
sgl3ject to the workers' compensation provisions of Section 3700 of the Labor
ode, I s all f h"< ith comply with those provisions: '
- j
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 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
cons uction, and hereby authorize representatives of this City to enter upon
th above-mentioned property forinspectio purposes.
Signature (OwnedAgent) Date z
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT TRACT7969
JOB SITE
APN
ADDRESS 44-630 N. {ilARIAND
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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USE OF PERMIT
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RECEIPT
DATE
BY
DATE FINAGED
INSPECTOR
iGRINKY TICIN �lC oo P',D
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Backs
Underground Ducts
orms & Footings
Ducts
lab 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
BLLOCKWALL APPROVALS
POOLS _ SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test of
.Final
Gas Piping '
PLUMBING G 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 —
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:
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