0002-104 (SFD)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 License__ is in full force and effect..'
License # < - Lic. Class 7 Ex Date
t!/ 11/<J• irleJ.fl.11f
Date` 17 `� Sign of ConfractorJ�.
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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, am exclusively contracting with licensed
contractors to construct the project (Sec. '7044; Business & Professionals
Code).Iam exempt under Section r 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. '
( ) 1 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 Y r POlicy, No.
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(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance"of the`work for which this permit is issued,
I shall not employ any person in any manno as to become -subject to the
workers' compensation laws of California, and agree that.if I� oulcl become
subject to the workers' compensation provisions of Section,37 0 0 of the Labor
Code'
11 I��sHall forthwith comply with .those'provis oi„ ns,,,,.._`
Date: %`�f ''' Applicant =�
f
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, 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 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`jaws relating to the. building
construction, and hereby authorize,representatives of this City to enter.upon
the above-mentionedprope yfor inspection purposes.
Signature (Owner/Agent) I Date
PERMIT# -
/.; BUILDING PERMIT 0002-11.1
9.�l1)(3 `
DATE VALUATION $Q��� y7y LOT 4 TRACTJOB
SITE
ADDRESS ` 8-.9,25 VISTA �.Rill•r4� O
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OWNER .:•
CONTRACTOR / DESIGNER / ENGINEER
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=i. t U1f� t t1 CA 922S3
LA. QUINYA CA 92253 _
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USE OF PERMIT
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RECEIPT
DATE
BYE' /
DATE FINALED"
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set BacksUnderground
Ducts
Forms & Footings
s
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
-440
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls r
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POO OAS
BLOCKWAL A PROVALS
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
COMMENTS:
Final
Utility Notice (Gas)
_
ELECTRICA AP ROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
-000
Sub Panels
Exterior Receptacles
G.F.I.
07 7
Smoke Detectors
/
Temp. Use of Power
Final
l
Utility Notice (Perm)
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