0101-341 (SFD)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
479689,
Date ? f =p Signature of Contractor , a rJ ^-
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.
( ),..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 Policy No.
atwiwlw EMMA
(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 provisions.
Dater?.?_T� Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines, upto $100,000, in
addition to the cost of compensation, damages as provided for:Ip 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. t
1. Each"person upon whose behalf this application is made & each person at `t
whose request and for whose benefit work is performed under or pursuantto
any permit issued as a result of this applicaton agrees to, & shall, indet-44
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null anis void if
work is not commenced within 180 days from date of issuance':ofs"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) ,� w�- ^^" '"� Date r-
BUILDING PERMIT PERMT#
D VALUATION. LOT ��� ,�+� TRACT
44 23971wI
JOB SITE
APN
ADDRESS
44-M) V9A CMOKADO
604-7.11--023
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LikQUYr`.3', A CA 92US
C 42253
USE OF PERMIT
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REDUCTION FOR MY.IL IPLF, i S.'!E.)MC9 f3Yr SAME PLAN TYPE /r
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TRACT CONS:E RUCTION 2769.00 OF f
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COMS.i UCTION M- 5 141 � +C3d i 0U4) $SdS3. G
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MECHANICAL Ful 101 -000-421 i,000 SN.50
E''LECTW'.;AL FEB 101-000.420-000
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RECEIPT
DATE !
BY
DATE FINALED
INSPECTOR
tt
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings 2`�
Slab Grade
Steel
MECHANICAL APPROVALS
Underground Ducts
Duds
Return Air
Combustion Air
Roof Deck
O.K. to WrapF.A.U.
C r i�
��
Exhaust Fans
Compressor
Framing
Insulation
S = / r% 4 (
(l`-
`G 44—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
Q�
,.��Final
Final _ _� jQ� 52-
BLOCKI FALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
2`�
�C
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral(�
Sewer Connection
Gas Piping
Gas Test
C C_
Pool Cover
Encapsulation
Appliances
Final
COMMENTS:
-
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 l/
Temp. Use of Power
Final
Utility Notice (Perm) ( "