0002-047 (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
'Professional§ Coae,•and my License is in full force and effect.
License# ' Lic: Class' Exp.. Date '
t�7wi&74 1
r,�� .
Date � Signature of Contractor
t OWNER -BUILDER DECLARATION
I hereby affirm under penalty, of perjury that.1 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). , . • .r
( ) I, as owner of;the.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:
µ ( ) ^I have and will maintairi 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., i ` Policy No. '
, r:� l ;i� a t�.A.• \tsV��. . _ tl'`c�r»%3if4 p'�•!J
(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,
l shall not employ any person in•any manner so as to become subject to the
workers' compensation laws of 'Califomia•, and agree that if I should become
subject to th"e,-workers' compensation_ provisions of Section -3700 of the Labor
Code, I shall/forthwith comply with those provisions. 1
Date: Y �r fr' 'Applicant
Warning:aFailure to secure Workers' Compensation Compensation coverageis�unlawful and
shall subject an employer to criminal, penalties and civil fines up to $100,00 in
addition to the cost of compensation damages as provided for in Sectio. 3 06
of the Labor Code, interest and attorney's; fees. /J
IMPORTANT. Application is hereby made toethe.Director of Building and/Safety
for a permit subject to the conditions sand 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 has alresult 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. Iagree 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 purpose's.
Signature (Owrer/Agent)
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Jl, BUILDING PERMIT PERMIT#1� ,.yy
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•DATE . VALUATION ��}��1� �' LOT 67 TRACT
29306
JOB SITE' ADDRESS 49-404'•1 VIO.A�Sd,?aLOMINll
APN
OWNER '
CONTRACTOR / DESIGNER / ENGINEER
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{_,.A QYIN:CA CA 92.253
LA QUEM A• CA 91253
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USE OF PERMIT
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L. SS PRE -PAID FEES
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_V.EES ONCE OW
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RECEIPT 7
DATE
BY /� J
DATE FINALED
INSPECTOR
J,s . 11'•11 •' � ... .. _ - r- ,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�+
Underground Ducts
Forms & Footings
(Gv
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
– p—a-c>
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
pv
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali insulation
-
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
.– � �� �--
Final
POO SPAS
BLOCKWALL
APPROVALS
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
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS.
Final Z–
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 3
Temp. Use of Power
Final
Utility Notice (Perm)