0308-347 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions
rovisions 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
Dhte Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt frorh the Contractor's
License Law 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 not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
1, as Owner of the property, am exclusively contracting with: licensed
contractorstoconstruct 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 for by Section 3700 of the !:`ab'Or Code,' for the
performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurancelas required by
SAtion 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:
Carver Policy'No. viAmmAuvir i
(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 shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700.of the Labor
C9de, I shpli forthwith comply with those prove . ions,
'b"
.6ate-'� Applicant Yplica
Warning: Failure to secure Workers' Com'ensation coverage is unlawful and,
shall subject an employer to criminal penalties and civil fines up to'$1 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 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,'
in
'de'
mni"w
& hold harmless the City of La Quinta, its officers, agents and employees. y
plo'
�1
2. Any permit issued,as a result of this application becomes null and v�Dicl 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 hav6 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 heieby authorize representatives of this -City to enter upon
the above-mentioned property for inspection purposes.4,-,
'Date- '�7/4
,,,,Signature (Owner/Agent)
tZY
BUILDING PERMIT
PERMIT#.
IrIONETIZVOTJON FEE
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OWNER
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'143-123 FRIM WAR, 9.3 R50-
'PAUA DEREXr' 922.60
PALM 131Y.SERT CA 92,240
32
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RECEIPT DATEY BY D FI E&.4. -.9 L SPECTOR ril.
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RECEIPT DATEY BY D FI E&.4. -.9 L SPECTOR ril.
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INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATE
I 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 APPROV L
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING hPPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
_
Water Piping j
Plumbing Final
Plumbing Top Out /
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping r 1W
Gas Test
Appliances
Final �-
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
-
Rough Wiring ✓
Low Voltage Wiring
Fixtures ol
Main Service
Sub Panels
_
Exterior Receptacles
_
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) r J