0002-023 (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
674 74 j . - f»�sii40i
Date `' Signature of Contractor l 'rte
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 & Profession'als 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. Iperjury .one • of the following `declarations:
O 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'.'338' • � Policy No. , - r-
• � 1 A'k llgrll�, .. • r ,
(This section, need not be completed if the permit valuation is for $100.00 or less).
( •) • l certify that in the performance of the work for which this permit is issued,
" I shall no_ t employ any person in any manner soar" t4 become subject to the
workers' compensation laws of California and agree that if I should become ,
subject to the workers' compensation provisions of Setction 3700 of the Labor
Code, J shall fio�rtHwith comply withrthose provisions./
Date: ! Applicant \- r =%"
Warning: Failure to,secure Workers' Compensation coverage,is unlawful and
-shall subject an employer to criminal penalties and civil fines up to $100,000; in
addition to.the cost of compensation, damages as provided for in Section 3706
of the tabor Code, Interest and attorney's fees. ,
IMPORTANT Application is$ereby made to the'Dire-ctor 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'mede & 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 cancellatiorit
I certify that I have read ihis'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 pure ses.' '
Signature (Owner/Agent) L� ` Dat
PERMIT #
BUILDING PERMIT
DATE VALUATION' ., �'�✓�()4a� LOT TRACTJOB
ADDRESS ` 8-4:��'I �V.�. •1.?6:.FA1{►f..3,j'1±e3: T4��
APN' `
OWNER
CONTRACTOR
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_DESIGN'ER/ENGINEER
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0 Box s r iie
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LAtqUliv'•1A CA 922.50
Lk QU•LWA C.R. 92252
(760)771-1941 Clil.," 4���6i ."
USE OF PERMIT
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RECEIPT
DATE
�Y ��
DATE FINALED
INSPECTOR
«
A J )
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade_
o
Return Air
Steel
Combustion Air
Roof Deck
Z
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
va
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
Z�
Final
BLOCKW
_
L AP ROVALS
_
POOL - PAS
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
�""_'
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection/y
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final _ /
Utility Notice (Gas) 21
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: