0401-180 (BLCK)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Charter 9 (commencing with Section 7000) of Division 3 of the Business and
. Profe sionals Code, and my License is in full force and effect.
A License4VTI�l
# Lic. Class Exp. Date13
-Da,teSignature of Contractor
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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.
() 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 IIATIO14AL IIN1014 Policy No. 716555
(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 provisionstof Section 3700 of the Labor
Code'ltshl II forthwith comply with .those provisions.
411 4Ppplicant el '1- OT'- 'I
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
-cor_Vrpiction, and hereby authorize representatives of this City to enter upon
the above mentioned property,for,inspeoti0'purposes.
Signature (Owner/Agent Date
BUILDING PERMIT' PERMIT"
(1401-180
DATE VALUATION LOT TRACT
•� / 1 r t / $2a,'3.:i5,00 Q3
JOB SITE
APN
ADDRESS 8) _*39 DHSF t! LLg'�'�° 1)IIMIC
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
MMLAQLTN—TAT.W
atJ1tA AQt[J1rfAUC
8) 269 ,AVT?WI rE 62
81 260 A'4i.ENi3•.I 62
LA 91.1tl YA CA 92253
TSA QUANTA CA 512753
(760)777.6005 10131.4 TC11D
USE OF PERMIT
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:i`i3fAL TIF.'MTF7!EMS DUE NOW
$54,00
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RECEIPT
DATE
BY
DATE ;QED
INSPECTOR
1
A
INSPECTION RECORD < i
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
;a
BUILDING APPROVALS MECHANICAL APPROVALS
i
Set Backs Underground Ducts
r
Forms & Footings Ducts
I i
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K to Wrap F.A.U.
Framing Compressor -
Insulation Vents
1
Fireplace P.L. Grills
;
Fireplace T.O. Fans 8 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 3_ Main Drain
- _
Bond Beam /% ,a !, Z, ��'/ � — Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final / Gas Piping
PLUMBING APPROVALS Gas Test
r
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
0
COMMENTS:
j
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
r
Final
Utility Notice (Perm)
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