9907-091 (SFD)ti LICENSED,CONTRACTOR DECLARATION
1.1 Hereby affirm under penalty of perjury, that I am licensed under provisions of
Chapter.9 (commencing with Section 7000) of Division 3 of A'business and
Professionals Code'and my License Is in'full force and effect.
License # ww Lid. Class Ex ..Date
14<
f�7
Date Ignature of;Contractor�
OWNER -BUILDER DECLARATION
I hereby affirm underpenalty of perju'ry 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•thelr' sole
compensation, will do the work, and the structure is'noi 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). .
O I, am,exempt-under Section, B&P.C.,for this reason
Date _,. t" ' ^ Signa_ lure' of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under'penalty,ofiperjury-one of, the following'declarations:
( ).,1 have and will maintain a certificate of consent to.self-insure for workers;
,compensation, as, provided for by Section 3700.ofthe Labor Code for the.
performan "'.of the workfor,which this permit is, issued '
(�);.;I have and will, maintain workers' compensation insurance, as required by
1 - Section 3700 of the Labor Code, for the performance of the work for. which this
permit-isiss7.ued: My workers': compensation insurance carrier & policy no. -are;,
Cartier Policy No ti
ry .
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`(This'section need not be completed if the peri `it'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 ecome subject to the,
workers', compensation laws' of Calif orniarand agree that if QShould become.,
subject to he wdrkers',compensation provisions of Section 3700 of the Labor
Code- hall fotthwith comply with thoseprovlslons.'
Date: f� Applicant V
Warning: Failure to -secure Workers Compensation coverage Is unlawful. nd ,
shall Subject an employer to'criminal penalties and,civil fines up to`$100,000; in'
addition to the cost of compensation;rdamages as provided for Iri Section 3706
of the Labor Code; interest and attorney's fees::
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit_subject to 'the, conditions and restrictions set forth .6n his
application. , i .. ,, , ' ,' 1
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant•to
any permit issued as a result of this applicator agrees.to,'& shall,..indemnify
& hold harmless the,City of La Quinta, its officers, agents and employees. .
2. Any permit issued as a result -of this application becomes null.and void,ifi,
work is not commenced' Within 180 days from date of issuance of"§d`ch z
permit, or cessation.of work. for 180 days will subject permit, to cancellation.
I certify that I have read this applicati61i and'state that the above informationkis j.
correct. I agree to comply with all City,.and State laws relating to the builaing yM
construction, and hereby authorize representatives of this City to enter upon,
the above-mentioned property for`inspectlon purp seS
Signature (Owner/Ag'ent)�' i bate �/ `�
.X,- BUILDING' PERMIT PERMIT
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DATE VALUATION .��c�$� LOT 40 TRACT 25:154 r
JOB SITE .., � p Qlq g!t� g {.
ADDRESS'v/%Z6-dD75 ♦ A Y.lf�& UNA
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OWNER , _
CONTRACTOR / DESIGNER / ENGINEER
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LA, QUINTA. ,' - � CA 92255
LA 0,U[NIA ' C"A. 92253
(70( )77.1-1911 CKY. 2996
USE OF PERMIT
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RECEIPT.
DATE
BY t.'
DATE FINALED
INSPECTOR
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
Q - -
Exhaust Fans
O.K. to Wrap
- j-
F.A.U.
Framing
4
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
d -
Final c� C�4
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
F-14, -
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
a 44 04
Pool Cover
Sewer Connection
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) 2 —/,0 -
COMMENTS: