0002-120 (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 forcd'and effect.
License,#_ Lic. Class Exp. Date «
0o4074 V401
DateSignature of.Contracto�,r—; o _ -✓�
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 isnot intended or offered for
sale (Sec. 7044, Business &,P,rofessionals Code): - , "'
(.) I, as owner`of the property, . am .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
' f
WORKER'S.COMPENSATION DECLARATION`,
I hereby affirm under •penalty of -perjury .one of the following, declarations:
O I have and will maintain a certificate of consent to self-insue 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
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`d"iri'X•� t.i�4i? Policy No. fAf�6��'n1?'fav
(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 p6mridis 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-lf"ftshould become
subject to't�he workers' compensation provisions of,Se ion /3700 of the Labor
Code, I sha(forf?Fiwlth comply with those.proions. C
Date: 4 10 -Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful nd
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 Jvith-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 inspectionp poses' l
Oigi`aturA (Ownoi'Jlgent)
BUILDING PERMIT PERMITwro),�,nh
DATE VALUATION 52,40,111.10 LOT 21, TRACT 29306
JOB SITE 49-5a/0A;&STA—CALIM
APN
ADDRESS
i
OWNER
CONTRACTOR/DESIGNER/ENGINEER
Tf'1 t1f'C Lys°0` t S !o'�]O Sim NiT
1 m U,t &..i, 0A A., 14.1
P; i� .t '1)TC 1'�/�AIS°"Ci1 i it"yP9•tflti;f
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PO ;88X, 1716
79-295 rONCHO Lik QUfV.r A DPL
L i QUINI-A :.A 92253
LA.QfJ.6N-VA CA 92253
(760771-1941 CBL# 29%
USE OF PERMIT
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4'Ce' Ai',, O'ERN i . + ±:fN DUE NOW
$4.442.03
RECEIPT
DATE
BY /'�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
-FUnderground
Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans or
O.K to Wrap
F.A.U.
Framing
Deus
Compressor
Insulation
,_ a—U
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
BLOCKWA
L PPROVALS
POOLS - PAS
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
g4j
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
®`
Pool Cover
Encapsulation
Gas Piping
Gas Test
z 4
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. 110,
Smoke Detectors
Temp. Use of Power
Final gyp/
Utility Notice (Perm)
COMMENTS:
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