0101-108 (BLCK)' '%
1 ~LICENSED CONTRACTOR DECLARATION
I hereby under that I licensed under of.
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PERMIT /t
BUILDING PERMIT +"
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affirm penalty of perjury am provisions
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Chapter 9 commencin with Section'7000 of Division 3 of the Business and
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DATE VALUATION
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v6Professionals,Code,'and my License is in full force and effect.
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'License # Lic. Class - Exp. Date
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JOB SITE
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Date Signature of Contractor
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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'I 6mb affirm under enalt of er u that I am exempt from the Contractor's.
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License Law for the following reason: -
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(') .I, as owner of the property, or my employees with wages as their soler
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compensation, will do the work, and the structure is not intended or offered for31.}s0i�^4®
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sale (Sec. 7044, Business,& Professionals Code).f
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USE OF PERMIT
(') . I, as owner of the:•property, am exclusively contracting with licensed
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contractors to construct the project (Sec. , 7044 -Business &Professionals—
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Code).
() I am exempt ,under Section- B&P.C. for this reason
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Date Signature of Owner
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CL Q WORKER'S COMPENSATION DECLARATION _
iO Q `Z I hereby affirm 'under penalty' of pertury''one of the following declarations;
0 ;N (") 1 have and will maintain a certificate of consent to self -insure for workers' 1Y'F. � p g, r
X•LLJ compensati, as provided''for by Section 3700�of,the Labor:Code; for the` 4,11•r "t1U'1�L . 2900 Le
O Q performance of the work for which this permit is issued ,
Cal C) ( Nave and will ,maintain workers' compensation insurance, as required by
O U' Q SSwoh. 3700 of the Labor Code, for the performance. of the work for which .this
Cl: rn` I— . permit Is Issued. My workers' 'compensation insurance carrier •&, policy no. -are:
ZCartier Policy No:
a0" 0 m1iru SIN ALITFI }1, . nAmOang'sao IMi!! ATAD COYr OF C 3NS INTIC'1MN
Q(This section need not.be completed if the permit valuation •is for $100.00 or less):
�� () Pcertify that In the performance of, the work,for which this`permit is issued, �"��''U�aydi# i 3;1� �(?m 3y3
.r I shall not employ any"person'in any, manner-so"as to become subject'to the S
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rkers';compensation laws of'California; and agree that if. I should become
1 subject to the workers' compensation provisions of Section'3700 of the Labor -
•� Code; I sh Ifo hwith comply with those provisions:
Date: 9 P Applicant
Iii-•' Warning. railure to secure Workers' Comp, ns ation coverage is unlawful and
shall subject anemployer,to criminal penalties and civil'fines up to $100,000, in
' addition to the cost of comperisation, damages as provided for in Section 3706
of the Labor'Code interest and attorney's fees.
IMPORTANT A plication is hereby made to the Director of'building and Safety
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for a permit subject -to • the conditions :and restrictions; set 'forth on his
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application`.' ,
1.•Eac6 person upon Whose behalf this. application is made &each person at :> "
Whose request,and+for whose benefit work is -performed under or pursuant to SUE► XTAL C;CaNMIVC 111014 AND PLAN CHECKany permit issuetl as a.'re'sult of this applicaton agrees to, &'•shall; indemnify t: �a •; e; T p ;y
& 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 ?' '
f .work is; notrcommenced; within.180 days from-date,of.issuance of such : T�.AL�? MITF I,�4�'r.110W
permit,'or cessation' of work for:180 days will subject permit to cancellatiori; r
s` l:certify that l,have.read this application and state thafthe above information.is
correct. I agree to comply With-II,CItV�:and State laws relating to•the building
construction, and hereby authorize representatives, of this City to enter upon .
the above-mentioned property forinspection purposes
p [ , �• RECEIPT DATE % BY�" DAT INAL D IP
Signature (Owner/Agent)xf A' Date
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PECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE I
INSPECTOR
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BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab 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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings �_ZcJ d� 6
Bond Beam
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Final U /
PLUMBING APPROVALS
Underground Plbg. Test
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
COMMENTS:
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
U61'Ry Notice (Perm)
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