9807-005 (RR)LICENSED CONTRACTOR DECLARATION
Cl)I.hereby affirm under penalty of perjury that I am licensed under provisions of
(—y `*'Aapter 9 (commencing with Section 7000) of Division 3 of the Business and
N;>LL '' Professionals Code, 'and my License is in full force ajW effect.
C C=) License # q Com" Lic. Class p: Date ���'t 4
I ?
IW
cZ r * Date Signature of Contractor—
CD
ontractor
0
U CCD OWNER -BUILDER DECLARATION
H Wd r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z( ) 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).
co O I am exempt under Section - , B&P.C. for this reason
to �-
N Date Signature of Owner
O N
Q WORKER'S COMPENSATION DECLARATION
Z I hereby affirm under penalty ,of perjury one:_pt the following declarations:
H O O 1 have and will maintain a certificate of corisenHp self -insure for workers'
K W Y= compensation, as provided tori by Section .3700 of the Labor Code, for the
nJ Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers' compensation insurance, as required by
jU Q Section 3700 of the Labor Code, for the performance of the work for which this
i U') H permit is issued. My workers' compensation insurance carrier & policy no. are:
"t ? Carrie Policy No. •s
CIS 7 p T'e F a: N. A cF' O 89
CY
g(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 provisior)s of Section 3700 of the or
Code, I s al fo wiftcomply with thos pr, dons.
Date: �sr 1! Applicant%
Warning: Failure to secure Worker's' 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
s 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 applicator 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�o cancellatiran.
I certify that I have read this application and state th the a. a information is
• correct. I agree to comply with all City, and Stateyla r�IAting to the building
Construction, and hereby authorize repro tatrV of,,tfiis City to enter upon u�
the above-mentioned property for ins ry osee.
Signature (Owner/Agent) = Date N
BUILDING PERMIT PERMIT# CONTFtOLN
iD3�1)'/-t311ti
DATE 7/1/4)8 VALUATION •i0[E.t10 LOT TRACT 8043
JOB SITE 51-049 iE LSk;1V4 0WFR 0H.
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
KA'1711Y MAYS
H.G. CON.'�rlft]JCTION
51-049EISFN'11OWLIA. DR,
4511 E. SLIRNY MJNI?
USPEC TMN RECORD
`Ad OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULDING APPROVALS
MECHANCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel A
Combustion Air
Roof Deck — ti
Exhaust Fans
O.K. to Wrap I
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
POOLS e SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLS UMSHG APPROVALS S
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
FinaE
Utility Notice (Gas)
EL ECT=AL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fi)dures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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