0002-042 (SFD)LICENSED CONTRACTOR DECLARATION
~ireby afflrf sunder penalty of perjury that I am licensed under,provisions of
pter.9 (coiit.,.encing with Section'7000pof Division 3 of.the Business and
Profes.;;or:als`Code, and my. License is in full force and effect.
1 License # LIC. Classy Exp. Date
64074
DateSignature of Contractor
t OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License taw for the following reason:
( ) 1, as; owner of the,property; or my employees with wages as their sole
compensation, will do the work, and the structure.is notintended 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). :, ; .o - -0.,.. •.t - •
O I.am exempt under Section' ,•B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION'
,I' hereby affirm underpenalty-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.
(-) 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.*
V
. �e•rsp.�rr{ . rt� _ t/,�p4 n•us?�9 e..
AGI,!✓
(This -section need not be completed if.the,perrnitvaluation ,is for $100.00 or, less).
(: );.I certify" that in the performance of the work for which this per is issued,
I shall .not employ any person' in any mann s to' become subject to the
-workers' compensation laws of'Californiareams aandd-agrel that if•I-should become
Subject to the workers"compensation•'provislons of Section 3780-f the Labor
r` Code, Ishall•forthwlth comply with tliose provisions.
Date: / f -:Applicant _.~� '
Warning. Failure to secure Workers'Compensation coverage is unlawful and
shall subject an employerto 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 Labor Code, interest and attorney's fees,
IMPORTANT Appllcatlon.is hereby made to the Director 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 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 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, and State laws relating to the building
construction, and hereby,authorize;epresentatives of this'City to enter upon
the above mentioned property (Inspection purpo es
Signature (Owner/ gent)%
a
ie --06 :BUILDING PERMIT PERMIT"
DATE VALUATIONt • �13 30 . LOT 62 TRACT •
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`
JOB SITE
ADDRESS •S&684dnST.A PALO'MiTiV `
APN . 1i66�r� 0 046 F
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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LA QUN-17A CsA 92253
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1�.A QUI TA ('.A. 92';53
(760)771.1941 • CBL #,,17�ffzq .
USE OF PERMIT
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RECEIPT
DATE".
BY/m} J
DATE FINALED
INSPECTOR.
N ,
` INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs _ Underground Ducts
s=f rms & Footings Ducts
Slab Grade .= p Return Air
Steel Combustion Air
Roof Deck _ Exhaust Fans
O.K to Wrap —ow AL1 F.A.U.
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWAYL
_
PPROVALS
Final
Steel
f _ 1�11 1
POO4S/SPAS
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
Heater Final
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
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice