0311-020 (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 Busineii and
Professionals Code, and my. License is in full force and effect.
,License # Lic. Class Exp:
7 J 76�tf Ppb
-_ "X:
Date
Signature of Contractor
X,
OWNER -BUILDER DECLARATION
I hereby affirm' under penalty of perjury that I am exempt from 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 r offeied for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of thlee"profp'e4,'am exclusively contracting with'kens6cl
contractors to construct* the -project (Sec. 7044, Busirieis. & Professionals
Code).
( ) I ameder Sectin B&P.C.'for this
D
x�
.1. xempt uno
.1 1., . 1. . -
Date - Signature of Owner
WORKER'S ;COMPENSATION DECLARATION
I hereby'affirm fbnder.-ppnalty. of iperjqry one of the following declarations:
w a ca e
have and 441 mintaiwa certifi te of consent to self -insure for Workers'
- I p I ro . vided ; or'. -by, Section 3700,.'of the jLab6r Codethe
, fo
..compensation;�.as f ,r
..Iperf6rm'AG�`of the wor,-k,for,* which this permit is issued ..,
SerI have and' ill maintain' workers' compenS4ti' on insurance, as required by
i ion Vbb,bf 46 Labor C6cle, for, the, peirforman6e of the work for which. this
permit is -issued Wy W&keis-, compensation .insurance carrier &' Oolicy:'.Ao. 'a4:
,'W '01 2T
Carrierqq 061icyNo. A243V 4723 ';' 11
(This section ne6d,'h8t l6e.6dmpl6iecl, if the permit valuation1s for. $100.00 of less).
..I certify that in,t e pe ormance of the 'Work for whichthis permit is 'issued,,
I shall not employ any pergoh�:in any manner so -as to bPcPm,e*bjeCt'to the
workers' compensationi laws!6f ' Cijifornia, and agree that if I should 1666omb
subject to the workers','c'om'-p 'en's'ation. provisions. of Section 3700 of,the.;Labbr
Code, I shall forthwith comply with those provisions.. i0;0
Date:' -2 �;"Ap- plicant
Warning:. Fai i'u r'e'6 'secu f e8', Workers' Compensation cove rag_eJs unlawful and
shall subject an employer to criminal penalties and civil fines up ta$100,000, in
addition.to the cost of compens . ation, damages asprovided for in Se6tioh'37-06
of the Labor t _ - -Wrest an * IdaIttorney's fees.
. I ' . . .
0ae�interest
IMPORTANT A' y made to th" Director. of Building gnd,`
Application e� Safety
for a permit (subject to the Conclitions and restrictions set forth 'on his
application'.
1. Each person' p6n-whose behalf this- application is madeA each person at
whose requ6it and. for whose benefit work is performed under or-P'Ufsuant-t6
any permit issued as a result of.this applicaton agrees to, & shall) inclemni
& hold harmless the City of. La Quinta, • its officers, agents anIll employ S.,
11111 d'
2. Any peripit issued as a result of this application becomes null ii void if
.work is not commenced within 180 days from -date of issuance oof sur�dholv
permit, or cessation of work for 180 days will subject permit to Lcali-ellatio"n J
f
I certify that I have read this application and state -that the above i forffi-aficin1s, 0
t I
correct. I agree to compf�miih 'all City, and State lav�s relating to the bui1VQ,9?dA
of
construction, and hereby authorize represeptatives this, City t on
the above-mentioned'property for inspection purposes.
Signature (Owner/Agentl (721':�-/` Date' L'e'4.42
�PERIVIIT#
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DATE 'M:0, VALUATION LOT TRACT r,
JOB SITE50
ADDRESS�'!A B,f VJAT1Ai,A YRA
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OWNER J.!
CONTRACTOR DESIGNER ENOINEFR
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2003
;.LA,QUINTA
ICE DEPT
RECEIPT
DATE
BY' LED
/O!��V S CT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVA S
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
4MY
Ducts
Return Air
_
Steel
L V__
Combustion Air
Roof Deck
i
Exhaust Fans
O.K to Wrap ,
Framing_
r
F.A.U.
Compressor
_
AV I I_
Insulation
'•
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
17 AvrZ
Final
,
Final
POOLS -SPAS'
BLOCKWAL
APPRO ALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVA S
Gas Test
Electric Final
Waste Lines
Heater Final
Plumbing Final
Water Piping so
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
.
r
Final
Utility Notice (Gas)
ELECTRIC APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring y
Low Voltage Wiring
FbQures
Main Service
Sub Panels j
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) – —
�' 1 -1v