0101-100 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of I perjury that 11am licensed under provisions of
Chapter 9,,(comMqpcing. with Section 7000) of Division 3 of the Business and
,,`Pr6fessioF,3:b t'dge' and'MY: License is in full force and effect.
License Lic. Class Exp. Date
1/02
W"
Date 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:
1, as owner of t ' he 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; Busineis & Professionals Code).
11 as owner of the property, am exclusively contracting with licensed
contracto . rs to construct the. project (Sec.. 7044, Business & Professionals,
Code).
I am exempt under Section B&P.C. for this reason
Date Signature Of. Owner
WORKER'S COMPENSATION DECLARATION
.1 hereby affirm under 'penalty of -perjury one of the- following. declarations:
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 W'il]4 maintain workers' compensation * insurance, as required by
Section 3700 of the Labor Code, for the performa rice of the,work for which this
permit is issued., My workers' compensation insurance carrier. &,policy no. are:
Cartier Policy Nbl.
I AMLFRII�AN 9 salt
(TOis.section. need r not be completed If the permit valuation is for,$100.00or 16ss).
I certify, that in the performance,of-the work,for which this permit is issued,
Z I shall not employ -any person in any Manner so Iamb become" subject to the
workers' compensation laws of Califorhia,,ancl.agre6 that if I should become
subject to the workers' compensiii6n provisions of Section on 3700 of th - e.Labor
Code,. I shall fort with comply' With ihos6 provisions -
Date:
Warning Failufe to Secure Workers' Compensatibn,covie'rage, is .6nlawf unlawful and
s,p
shall subject,an'employerto criminal penaltieirid civillfines up to in
addition to the CbStrof compensation, damagps"a§ provided for in'Section 3706
of qhe Labor Cod6,- interest and attorney's fees.
IMPORTANT Application is he reby.made to the'Di rector of B u i Iding, 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 for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &'shall, indemnify
holdd-harmless the City of La Quinta, its officers, agents and employees!'
2. Any permit. issued as a result of this application becomes Pull and void if
,work is' not commenced within 180days from date of issuance of such
permit, or cessation of work for 18.0. d . ays wi . 11 subject permit to Cancellation.
I -Pe . r . tify that I have read this application and state that the above information is
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-mentidned property for inspection purposes.
2
Signature (Owner/Agent) Date fh,
BUILDING PERMIT PERMIT#
DATE VALUATION LOT • TRACT
JOB SITE*
APN
ADDRESS,
7-9
4'40 VIA ZU'RUMt-
OWNER
CONTRACTOR/DESIGNER/EN INFER
CM&DAY&COW.Alwy
0ARADXf & (K)MRARY
11460X 1711,011. 0106
11480 Z 771191'. it] 06 j.
T(JUM4 CA 9T? 80
IYUM1114 CA .92780
'714)5 08-4440 MEL# 4485
USE OF PERMIT
N& L? 64 1S1j)X WAM,
30 IM 4'COURTYARD WALIA, 011TANDARD,
0 I'M WALL =00 Lit
4 FT,
RIMAM COST OF COMMUCYTON
T'sm loi-000-438.00t)
'4
�RAU ET.
LE12:3 PRE XF S
40.00
TWAL FETMI I MS DATE BKOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
or" r?
Awl
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
- DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Se. Backs
Underground Ducts
Forms & Footings
Ducts
S_ab Grade
Return Air
Steel
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Footings ZWK
Electric Bond
Main Drain
Bond Beam. �� �� _
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
_ _
Final
PLUMBING AROVALS
Gas Piping
Gas Test
Electric Final
Waste Lines
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
Appliances
Final
Final
I ELECTRICAL APPROVALS I
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
Utilitv Notice (Perm)
COMMENTS:
6ld—