9912-048 (BLCK)4 LICENSED CONTRACTOR DECLARATION
71
�U) .1hereb affirm under penalty of perjury that ' I am licensed under provisions of
r 9 (commencing with Section 7000) of.Division 3 of the Business and
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C14 UJ Professii-�nals'Code, and rn� License is in full force and effect.,
C) License # Lic. Class Exp. Date
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LLJ. 035 fr,"Akli
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OWN ER-BUI LDERPECLARATION
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W UJ I hereby affirm under pii�alty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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Z 1, as owner of the propert y,'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
1, as own& of the property, . am exclusively contracting with licensed,
contractors to construct.the project (Sec. 7044, Business &,Professionals
CodO. t, , ; :, , . . . , . , . .1 1
Cf) I am exempt under Section'—, B&P.C. for this reason
LO I I I I
C\1 Date Signature- of -Owner
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< WORKER COMPENSATION DECLARATION
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2 cr I hereby affirm_under penalty of perjury pne of the following declarations:
U—,) �<-- 0 - . (,) , I have and wil,l. maintain a. certificate of consent to self -insure for workers'
"X W LL compensation,' as provided for by Section 3700 of the Labor Code, for the
0 -performance of thework for which this permitisissLied.
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< 0 lhaveandwill maintain workers' compensation insurance, as,requiredby
d q Section 3700 of the. Labor Code, for the"performarice of- the work for which this -
12� LO permit is issued., My, workers' coi4ensation i6stirance carrier & policy no. are:
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< (This section need not be completed if the permit valuation is for $100.00 or less).
_J I certify that in the perforr�ariice oi the work for �vhich 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 work&s' cor�pensati6`nprGviS`io6s of section 3700 of the Labor
C6de, Ish ll.forh7ith com�ly with th
Date. 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 cor�pensation, 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
for a permit subject to the conditions, and riistrictions set forth on his
application.
1. Each person upon whose behalf this applicatidn is made & each person at.
whose request and for who"se'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 e ployees.
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,*a'nd State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
i the above- mentioned'iIrope rty,f df inspectibri-purposes.
Signatu . re 1 (Owner/Agerit) Date)dC/V7
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PERMIT#
BUILDING PERMIT
111A 11
ft
D VALUATION S1,775.00, LOT 105 F�ACT .1.2 11 �_14
ATE
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JOB SITE '7.A,19031VJ_A FLORACN01,
ADDRESS.
JAPN
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OWNER
CONTRACTOR DESIGNER ENGINEER
-'AIN11 A r'A A'V,.X% 0, T) Aklv
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INS 708
1 k0d,�HOLLOWT FAUVIE" SUITE, 20S
SANTA A N ik G"A 92-10S
SANTA. i�NA CA Moi
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USE OF PERMIT
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r—CEIPT
F"
DATE
BY
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17
INSPECTOR
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
Final
Final
BLOCKWALL APPROVALS
POOLS --SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
�p7�
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
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
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)
COMMENTS: