0211-063 (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
7776911,�r
eA•'ate f� 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 owneraof the property, am exclusively, contracting with licensed
contractors to co6struct 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 per'jury 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
S cfibn 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 .. MTV MUTUAL A L .M Policy No.
(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`th'e workers' compensation provisions of Section 3700 of the Labor
Code, I s all orthwith comply with those provisions.
ate j. z,, Z. — ApplicantAW el,��
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 pursuarft 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. ss
Signature (Owner/Agent) L% Date/Li, itv "
BUILDING PERMIT PERMIT"
:
DATE VALUATION r LOTTRACTJOB
SITE ]AP
ADDRESS'C".�? R.E+A1Ps ,
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
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USE OF PERMIT
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DOVRfLI PUR 1M1P.P!C T IrEE,4MS..00
ART ilk PUiiUO PLACE0 - RESW Z-70- 00.40-00 $94Z
� .. PREAP:{UD :N311 3
$0f 00
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nor •
CITY OFLA OUiNTA
ECEIP.T 'FINANCE
AftT.
BY
DATE FINALED�` �.
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings g
Ducts
Slab Grade
Return Air
Steel 17
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath . o
Drywall - Int. Lath •G
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 APP OVALS
Waste Lines _ _ _ _
Water Piping i
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _ J _
Pool Cover
Sewer Connection �/��/
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
I ELECTRICAL APPROVALS I
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utilitv Notice (Perm)