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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
637,25r2 . B, -
Date 'gnature of Contractor
V
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, as owner 6f 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 & Pr�fessionals Code).
( ) 1, 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'h-ave and will maintain workers' compensation insurance, as required by
Section 3700 of the Lab6r Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
el 11 v., � A k It VC, ..0, r., w v%
(This section need not be co�npleted 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 tho 0
Date: QPkIpplicant—
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employerto 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 applicatoh agrees to, � shall, indemnity
& 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.
Signatur e (Owner/Agent) Date
-7 KZ7
BUILDING PERMIT PERMIT#
,1,,IIALUATION LOT TRACT
JOB SITE
APN
ADDRESS 75-6is5 Dii,5EAL74" WILLOW SI'RIL'2111'
OWNER
CONTRACTOR DESIGNER ENGINEER
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IKVINE (�A 92o14
1911t) 12.5 1 -6100 30112
USE OF PERMIT
501.) �,LOT 6.4 iw.LA1q 2 D013-3 1401' INCLIMEBLOCK -WAT.J. Oit
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01*1A,01111-40. F334 11120,(110
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D'VE N(AV
IDATE
1BY
ID . ATE FINALED
INSPECTOR.
NC
INSPECTION RECORD
OPERATION
T_ DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Z -7
Steel
Combustion Air
Roof Deck
7T 1�5- C) I
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
e2_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
44
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
Waste Lines
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
gv
Equipment Enclosure
ShowerPans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
7� :/:_1
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final 4
Utility Notice (Gas) �z Z�_,
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring -ep/
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
I Utility Notice (Perm)
COMMENTS: