9701-073 (MISC)t LICENSED CONTRACTOR DECLARATION
(.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
C\J W w, Professionals'Code,_and my'License is in full force and effect.
p Z (h License # Lic. Class -"" Exp Date
Z Date j ` Signature of Contractor {=^�"A-"-^'•-""'��
CJ° U OWNER-BUILDER-IJECLARATIONN.rf''
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1.hereby affirm under penalty of perjury that I am exxempt`from the Contractor's
•
License `Law for the following reason: _ell
Z_ ( ) 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).
( ) 1, as .owner of the property, am exclusively wntracting with • licensed
contractors to construct the project (Sec. 7044, Business &;Professionals
Code).
C`) ( ) I am exempt under Section ` B&P.C. foF this reason•`
N Date Signature of Owner- -
U Q WORKER'S COMPENSATION DECLARATION..',
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o< CrI hereby -affirm under penalty .of perjury one of the following declarations:
LO � O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for, the
O J _J performance of the work for which this permit is issued. ,
00 Q U () 1 have and will maintain workers' compensation insurance; as required by
O U QSection 3700 of the Labor Code, for the performance of the work for which this
d LO H permit is issued. My workers' compensation insurance carrier &; policy no" are:
Z Carrier Policy No: .•'
6iJ1'1'F1
rJ (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 manner„ so asi toybecome subject to,the
workers' compensation laws of Calif ornia;''
and �agree that if I. should become
subject to the workers' compensation: provisions of Section 3700..of•the Labor
3 hal
e, (sl forthwith comply with those,pr6isibnsl
.
,."Date Applicant !- ✓ +
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 of
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-mentioned property,forinspectio�n purper�es .7 .
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Ignature (Owner/Agent') ^' x
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-BUILDING PERMIT PERM' �# �� CONTROL# r
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DATE r VALUATION LOT' 40 TRACT 2 VH.,1
J 0 B SITE• APN
ADDRESS 7_9-.A0 VIfapr
COURT t tr*343-071
OWNER CONTRACTOR / DESIGNER / ENGINEER
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;sA'�!' 63t i7 ?.klE?i iN3 CA 97,10-3 .AN, `i�V.li.NA.k.0iN0, , CA 0,21 1F2
USE OF PERMIT': < Y, - ASSOC •.O
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RECEIPT r DATE BY DATE FINALED INSPECTOR
0.0-1) '
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
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
LEE
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
Utility Notice (Perm)
COMMENTS:
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