0201-084 (BLDG)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 k Lic. Class Exp. Date
'73152 B 3/33.11()3
Date f — Signature of Contractor
T
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
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.
(fi 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
STATE FITN!) Policy No. OA60J UNITOo09415
(This section need not be completed R 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 3 y00 of the Labor
Code, I phall forthwith comply with those provisions/ ;
Date: �a 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 0 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 perforn6i4.under or pursuant to
any permit issued as a result of this applicaton agree�to,.& shall, indemnity
& hold harmless the City of La Quinta; its officers, agent's agd'pmployees.
2. Any permit issued as a result of -this application becomes nulf 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.
Signature (Owner/Agent) s / r ' ' •l �!' f Date' ,
BUILDING PERMIT PERMIT#
DATE r VALUATION LOT 0201--W4 TRACT
JOB SITE /
ADDRESS
52�
APN
iIkL�l,�i,UNIv v
OWNER
CONTRACTOR / DESIGNER ( EN INEER
FIGA. WEST R.:o.%L1EN TW., AMOC1J3'1 TON
DEX. MAR PACIBTC OE ET6Q. C0KfRAC'i0R
PO DOX 1060
2533 SOVER COXITHIGHW/tY STK 230
LA..QG1N1'A CA,
r.:,'A 92007
('160)501.9500 C..B1.4i 323
USE OF PERMIT
Mtst"EUAW_- OU:i
tftdILDINQ 3'1 • w9.043, `M-Obx� S/I.OT/, 54.089 - VOLUNTARY
:7TRUC"•T9RA1,. MODIFICATIONS
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C0149TRUCTION AEN.'-' 101-000-418..000 $2o`1.oa
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TO FAL rERMTF F€F:S DUE NOW
RECEIPT
DATE. /
BY
DATE ALE
INSPEC /
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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
BLOCKWALL APPROVALS
PdO' M - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
as Piping
PLUMBING APPROVALS
Gas Test
Electric Final " }'
Waste Lines
Heater Final . .
Water Piping
Plumbing Final.
Plumbing Top Out
Equipment Encbsure
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)
TCL-
COMMENT