0002-103 (SFD)LICENSED CONTRACTOR DECLARATION t
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 in full force and effect.
License # Lic. Class Exp:, Date
/6
�740
�4
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:' -
( ) 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
sale (Sec. 7044, Business & Professionals Code).
( ' ) I, as owner.of the, property,;ani 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 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, asprovided 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
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` Policy No. +'
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(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 Califo�ia" a1 d agree that,if'I s could become
subject •to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those•provlsions.
Date: /i,'L/n•s Applicant..',
Warning: Failure to secure. Workers'• Compensation coverage is unlawf)a1 and
shall subject an employer to criminal penalties and civil fines up to'$10Q;000, in
addition to the cost of compensation; damages as 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 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
& hold O
harmless the'City of La uinta, 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 1$0 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-mentioned property -for inspectio pur1poses.
Si nature (Owner/A e )�"`"� G� Date�X/c
PERMIT#
r 6 J BUILDING PERMIT
DATE VALUATIONSa0,R•�`,�,�:� LOT TRACT 2(jjj
JOB ADDRESS Qti E �r1 �+ iS A � .F�D.�..�.� �3 - --- ._. -
FAP
CONTRACTOR DESIGNER / ENGIN/E-EEyR�
OWNERry
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LSI QUiNTYX CA 92153 LA QUIM.17A o' CA. <32:u53
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USE OF PERMIT
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RECEIPT
DATE
BY d l
DATE FINALED
INSPECTOR ,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS 4
Set Backs
Underground Ducts
Forms & Footings
LP
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
.-�,3 p-0
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 Wall Firewall
Exterior Lath
oe
49,
Drywall - Int. Lath
_
Final
Final
BLOCKWALI_ A PROVALS
steel
POO - PAS
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
— —7M,
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
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 Z
Utility Notice (Perm)
COMMENTS: