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 # Lic. Class_ Exp. Date
Date ' ' " ' Signature of Contractor ' f
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.
(J) 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 SPolicy No.
STATE F01•II1 0160 0?7)TOD00415
(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 becbine
subject to the workers' compensation provisions of Section 3 )00 of the'Labor
Code, I shall forthwith comply with those provisions, j
Date:i! 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:Vk 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 performieq.under or pursuant to
any permit issued as a result of this applicaton agrees' o,.& shall, indemnify
& hold harmless the City of La Quinta; its officers, agents and employees.
2. Any permit issued as a result of this applicatiA' becomes nuB and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 160 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) t r `l I �� / Date'',
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BUILDING PERMIT PERMIT#
DATE ' VALUATION LOT 0201I.-IIA4 TRACT
JOB SITE
ADDRESS
APN
FiiMS' ONr �L /
OWNER
CONTRACTOR/DESIGNER/EN INEER
PGA VE . "31' 14,S1C►1KNTLA& ASSOCIATTOW
DFS, lifAR PAC 51C', OF..tJ Ckk, COAd`MAMOR
PO 1?{1;x',1060
2533 :Mi1'H 1770A:T]'1.11Cr7.IWAY a'.t%: 2.50
11ti QExt:WrA CA
CA1.131.tI LY`1 E MA C,A. 9200
(760)5&1-9500 Mill !M3
USE OrFrPERMIT
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I'MAL rERMTf 1117S DUE NOW
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RECEIPT
DATE; r
BY _
DATE_F ALE
INSPEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts -
Forms & Footings
Ducts
Slab 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 8 Controls
Party Wall Insulation
Condensate Lines
-Party Wall Firewall
Exterior Lath
'Drywall - Int. Lath
•n
Final z� ;
......:.�
Final
<:...:..
POOLS - SPAS
BLOCKWALL APPROVALS
Steel •
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location :_.v.,._ _•,
Underground Electric -
Underground Plbg. Test -
Final
Gas Piping `• 'f
PLUMBING APPROVALS
Gas Test •
Electric Final ::: , *'�
Waste Lines
Heater Final .: ......=•
Water Piping
Plumbing Final_•
Plumbing Top Out
Equipment Enofosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
. P:ool :Cover
Sewer Connection
encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENT 0.
//ZA/
U
! ,
I
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
FbQures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)