0307-260 (RC)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 Licens�:-is In fs: l force and effect. t
Licensel1#{ �'yyp,yff " r°" Lic.Class" Exp. Date
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Date 1.,x WF Signature of Contractor • `F,; "`•r -^'
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury 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 their sole
compensation, will do the work, and the structure is not intended or offered for
AnlP (Ser. 7044, Rusinegs R Professionals Code).
( ) I, as owner of the property, am exclusively' contracting with licensed
contractors 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. !-
I 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 will maintain workers' compensation insurance, as required by
r
Section 3700 of'the Labor Code, for the performance of the work for which this
permit is issued: My workers' compensation insurance carrier .& policy no: are:
Carrier S 4°.A TFI h"UNT'D Policy No. 464 93,
(This section need'not be completed if the permit 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 become subject to the
workers' compensation laws of California, and -agree that if I should become'
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shill forthwith comply with`those pro'vlslons. rt <
Date: Applicant .y ,"..- : k
_ t+
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damagesas provided for in 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 6m..his
application. �v.
1. Each person upon whose behalf this application is made & e•ach 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
& 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 days from date of issuance of such'
permit, or cessation of 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 mentionedipropertyM1for Inspection purposes.
Signature (borne%Agent); •1�- =y� tom`^•�-�^ Date
T#^
-BUILDING PERMIT PERMIWy -so
^
DATE ha' 'VALUATION o�yjO�S�,Q �f _LOT y - TRACT _
ADDRESS .)t E p tdj aS1 �.lE J� �rLJV
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OWNER
CONTRACTOR/DESIGNER/EN INEER
ITI,:1.•S.e'}
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USE OF PERMIT�
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JUL 2 3 2003
CITY C1Ft,�aflFlr"sA
' FlRe6N4rI�
`'
RECEIPT ""'DATEBY
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Q FI D
INS OR
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Ins dation
Vents
Fir lace P.L.
Grills
Fireplace T.O.
Fans & Controls
Par"y Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath1j0
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
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
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
:C , OMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 'f
4!ow Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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CITY OF
LA QUI
BUILDIN &
SAFETY T.
AP
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A RE -INSPECTION FEE 0 30.
=%NEAPP ED ARE N _ ON
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