0301-059 (SFD).. ..; .. ,. .� _-..- _ ✓ . .Q.- :r ..•.. .: fin' ..
> LICENSED CONTRACTOR. DECLARATION .
I hereby'affirm under penalty of perjury th'atl•'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# ; Lie.,Class Exp. Date
614074 B Ate f31 M
Date - �' Signature of Contractor
� �' •_ ., • 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).
( ) 1, as owner ;of; thea property; am exclusively contracting With licensed
contractors -.to. construct' the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section B&P.C. for this reason
Date Signature of, Owner
WORKER'S COMPENSATION DECLARATION
1; hereby affirm under penalty of perjury one of the following declarations:
O I have rand will.main'tain 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.
�( 1) I fiave 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 STA .LIFIR Policy No.
(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 provisions of Section,3700 of the Labor
.,.Code, I shall forthwith comply with those`provi ` fns,.., '";` ,.
Date f 1. • •.' Applicant i
`Warning Failure to secure Workers' Compensation coverage is unlaVoful 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
fora 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
construction, and hereby authorize representatives of this City to enter upon
the above -_mentioned property for inspection purposes.
"Signature (Owner/Agent)
BUIL°`DING'.PERMIT PERMIY. �.
DATE VALUATION' s 4W**1 g&,9 LOT, ' TRACT
JOB SITE
ADDRESS,,
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
M DEnSMr� DEM-OPIVIEW
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CA 9225
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USE OF PERMIT
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RECEIPT
DATE
BY
DATE FIALED
INSPECe—
4
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
7_
Exhaust Fans
O.K. to Wrap
-23 — `5
F.A.U.
,
Framing
Compressor
Insulation
77L
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
z
Condensate Lines
Party Wall Firewall
Exterior Lath
c
Drywall - Int. Lath
Final
�— t
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test,
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lin
Heater Final
Water Piping
Plumbing Top Out
c/
`
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
SeNer Lateral
Pool Cover .
Sewer Connection
—/ 7 — 3
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 AlSub Panels _
Exterior Receptacles
G.F.I. _::4 -
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: