0304-122 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury:tha6 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
B RIC 61301104.
Date w;<� 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 property, am exclusively contracting with licensed
contractors to construct the,.project (Sec. 7044, Business & Professionals
Code). �.
() I am exempt under Section B&P.C. for this reason
Date' Signature of Owner
oti ,
WORKER'S --COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
O I have and will maintain' a certificate of conseht•to self -insure for workers'
compensation, as provided:Afortby Section 3700of',the Labor Code, for the
performance of the work for which this permit is issued.
( )A I have and will mairitaiq.workers' compensation' insurance, as required by
See$on 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 IT.lt'!'E e+'UND Policy No. 10A,62_0?
BUILDING PERMIT PERMIT`
DATE VALUATION ?er• 21� :�: LOT .. 4.6 TRACTJOB SITE
ADDRESS _ca�J%1 APN
OWNER
SEX—, ?N.s+b. H0'3+rO% 1114C
774564 COil2i TRY CIII i�'%D7UVR M1 ITE 137
USE OF PERMIT
(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
Code, I shall forthwith comply with those provisions.
'Date: • ? -'Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to 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 Application is hereby made to the Director of Building and Safety.,
for a permit subject to the conditions and restrictions set forth on his�,t
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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
C.� RE(
Signature (Owner/Agent) Date r 7#=rte
P004 SPA Cid:. OPqNtcsWAY.A .PROACK
CONTRACTOR/DESIGNER/EN (NEER
CNDPIPOPA !10114
CA. 92`43
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MAY 2 7 2003
CITY OF LA QUINTA
FINANCE' DEPT.
EIPT DATE � % By DATE ALD
A ��a9q;�Rh7 riW
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
Framing
/
F.A.U.
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
BLOCKWALL APPROVALS
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 AP PRROVAL
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
,Sewer Lateral
Pool Cover
,:Sewer Connection
i
Encapsulation
Gas Piping
Gas Test
Appliances
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: /
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