0311-018 (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
Date Signature of Contractor
�.
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 pi�opeity, 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
I hereby affirm under penalty of*'perjury one of the following declarations:
() I have and will maintain.a certificate of consent to self -insure for workers'
compensation, as. provided ofor 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:
Gamer P1Is.J',S Ui ,r 3F' . Policy No.
(This; section need not be completed if the permit valuation is for $100.00 or less).
O I.certlfy'that in the performance of the work for which this permit is issued,
I shalkhzi employ any person in any manner so as to become subject -to the
workers' compensation laws of California, and agree that if.,l should become
subject to the workers' compensation provision$ -of S,eption 3700 of the Labor
Code, I shall forthwith comply4ftt: those pppvIsionsT-'
Applicant 1 -7' •
Warning Failure to secure Workers' Compensation coverageis unlawful and
shall subject an employer to criminal penalties and civil fines $1-Q0,0.0.0 in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. ID
�—
IMPORTANT Application is hereby made to the Director of B Iil8in and Safe
PP Y it r 9 � tY
for a permit subject to the conditions and restrictions sWt hforth �'o�}�Is1,0
application. I
1. Each person upon whose behalf this application is made & each p2ison�at-
whose request and for whose benefit,work is performed un er or purst�ant�1g,OE'
any permit issued as a result of this applicaton agrees to, a f—'Fir 'demnify
& 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.
1
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 representatives of this City to enter upon
_ _the above-mentioned property for inspectt�p6poses..
Signature (Owner/Agen� •--A�
PERMIT #'
BUILDING PERMIT
oa'll.ot§
DATE VALUATION Y%® LOT TRACTJOB
SITE"
ADDRESS. ♦�Or(atSfC� did
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
1,41EYft% arae
73-121 R WA
^.WRIM
1 FRYD W
Ch R2760
1
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USE OF PERMIT
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RECEIPT
DATE '
BY
DA FI �
I
PECT
/.
i
INSPECTION RECORD
OPERATION
ATE
INSPE TOR
OPERATION
DATE
INSPECTOR
BUILDING A PROV,ALS,/,,MECHANICAL
APPROVALS
Set Backs it
Underground Ducts
Forms & Footings
ucts
Slab Grade NJ
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U. /
Framing
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
arty Wall Firewall
Exterior Lath
Drywall - Int. Lath
i
Final
Final _4 4
BLOCKWALL A PRO A
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP OV $
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Top Out �—
Plumbing Final
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral A I
Pool Cover
Sewer Connection °y, FP7
Gas Piping
Encapsulation
Gas Test
Appliances 10
a.
Final
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)
COMMENTS: