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>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 #" ` Lica Class, 'Exp., Date
o� 7'=i3 �i 'Y7 lull
Date X Signature ofyContractor '
7.
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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& Professionals Code).
( ) I, as owner of the property, .am -exclusively contractingwith 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 ofiOwner'
WORKER'S COMPENSATION DECLARATION -
I hereby affirm, under penalty ofe'perjury one of .the following declarations:
() I have and will maintain a certificate of consent tc,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 iso issued.,' My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
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(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, .
I shalLnot employ any person in any manrier so as-to'btecome subject to the
workers' compensation laws of California;.and,4 ree that if I should become
'subject to the"workers' compensation provisions of -Section 3700 of the Labor
Code, I shadforthwith comply with those provisions.
Date://, /�! y Applicant %
Warning. Failure to -secure Workcri4o pensation coverage is u lawful and
shall subject an employer to criminal penalties`and civil fines'up to V 00,000, in
-addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.,
IMPORTANT' Application,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 belialf 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 -1 have read this,application and state that the'above information is
correct. I agree to comply with all`City, and-S4ate'laws relating to the building
-construction, and hereby authorize representatives of this City to enter upon
the above-mentioned 1property for inspection purposes.
Signature (Owren/Agent)"� Dat , �/
' BUILDING PERMIT PERMITfi# d;tyy ``pper� '
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DATE VALUATION rh�r�%:51. LOT TRACT'--
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OWNER
CONTRACTOR DESIGNER/ENGINEER
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"79 2 5RANC.HO LA QJINrA DR.; ' •
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T.f1. Qi„ INIA CA 92253
'LA t7U1N2A CA
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USE OF PERMIT
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RECEIPT •,
DATE 7Y,T
x%
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
_y —
F.A.U.
Framing
I e's
Compressor
Insulation
yea
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
— —
POO - PAS r
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
Gas Piping
Encapsulation
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 la /z vz�
Utility Notice (Perm)
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