0002-207 (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 rn full force and effect. ?_
License # Lic. Class. Exp., Date
674074' ! l►iJ S!/zUl
✓;
Date.777 `� ,7 Signature 0f.Coratract,or'
7 - rs r:
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OWNER -BUILDER DECLARATION
I hereby affirm under penalty.of.perjury that tam _exempt from the Contractor's
License Law for following reason:
of the' property,: or my -employees'with, wages as.their sole
compensation, will do the work; and the structure isnot intended or offered for
Sale'(Sec. 7044, Business& Professionals Code).
:( ) 1;-as•owner of the property, am•ezclusively: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
:t :WORKER'S COMPENSATION DECLARATION
I hereby:affirrri under.' penalty, of, perjury.one �of`the following declarations:
) J have and;will•maintain a certificate of consent to self -insure for .workers'
compensation; las provided -for by Section 3700 of the Labor. Code forthe
performance of the work for which this permd,is'issued -,
(,) ,I -have :arid will maintain workers' compensation insurance, as required'by
section 3700 of the Labor Code, for the'perf&rnanceof the work for which this
°• permit'i's issued. My workers compensation. insurance' carrier & policy no are:
C2rrler. ''_ .,Policy. No.,, - t .. /, f/G.�} .
-SVO
(This section'need not be'completedif the permit valuation is for $100:00 or less):
..O I certify that in: the.performance of the'.work for"which this•permitis issued,
,.I.shall'not employ any person in any manner so as.to become subjecfto the
workers' compensation laws of `California, and agree that if'I should become.
subject: to the. workers„ compensation provision of Sectio3700 of the Labor
Code; I shall'forthwith comply with'those provisionss.;s'"
r 1•
Date.' �'� : g Applicant f c
•Warnin ..FailureNtosecure Workers'tCompensation coverage'is.unlawful and
9
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 attorne.y's fees.
IMPORTANT, Application is hereby madeVto`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'fori-4hose benefit work is performed under or pursuant to
any permit -issued as a resuit'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 2 days` from date of issuance of such
permit, or cessationof.,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
Signature (Owner/Agen't)1 f t t '!Date V�7
BUILDING PERMIT PERMIT# .. ,
207
DATE' 1 / r -VALUATION" - -* j.79 LOT' TRACT
JOB SITEL`
ADDRESS 79-944 1A YV1:.1J•.�Fsl,l A - �
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APN
UWt► J.�J �1��&
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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.79-293:PLANci4o u, QUiN*rA 'm'
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USE OF PERMIT !
SINGLE ۥ',AMii. Yr MVELTJXG
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RECEIPT
DATE
J,BY ° ^' —
DATE FINALED '
INSPECTOR_
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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
O.K. to Wrap
Framing
AIC-.
-
6z
��_
Exhaust Fans
F.A.U.
Compressor
�l� !�•�
Insulation
p�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
v 2�
Final
Final -
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_ f
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
l•
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: