0101-261 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
c 'Z, Jhapter 9 (commencing'with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
O :3 ch License # Lic: Class „�., rW^°" Exp. Date r
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ture of Contractor �►
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J U OWNER -BUILDER DECLA ATION�
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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.- 7.044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of , Owner
WORKER'S COMPENSATION DECLARATION '
h hereby affirm .under penalty ,of perjury 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.
(�) 1 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.
2TA TF.,1i1' D i39�dtf la•fi� ' .
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the wol;kAor which this permit is issued,
I shall not employ any person in any 'mgp,Fier so as to become subject to the
workers' compensation laws of Ca4IYc la, and agree that if I should become
subjectlo the, orkers' compensat on. provisions of Section 3700 of the Labor
Code, h II ford w th comply with tho e. r�ovisions..
'Applicant��r,;.
Warning5 Failure to secure Workers'l�enaltieis
ompensation coverage is unlawful and
shall subject an employer to criminal 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;. nterest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a p.e_"rmit 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 Y
& 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 cancel lation°}
I certify that I have read this applicattign.and,state that the above information is t
correct. I agree to comply with��f ll'City, and State laws relating to the building
construction, and hereby au'fhq�rize representatives of this City to. enter. upon
the above-mentioned prb�perty�� >`linspection purposes.
4
Signature (Owner/Agent) f-_� ' Date
BUILDING PERMIT PERMT#
DATE ..VALUATION LOTTRACT
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RECEIPT
DATyEBY{
DATE FINALED
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
-
steel
3e
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location_
Underground Electric
Underground Plbg. Test
_
Final I
Gas Piping
�(o
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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
_
Gas Piping
Gas Test
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
Temp. Use of Power
Final
Utility Notice (Perm)