0009-241 (BLCK)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. '
Licerk% ^' • .. Lic. Class -' Exp. Date.
Y 1`
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: -
(�)r 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).. x
( ) .I, as owner *of the property, am exclusively -contracting with, licensed
contractors to construct the: project (Sec. 7044, BY mess & Professionals
Code). �,r r
( ) I am `exempt under Section , B&P.C�fof this reason
Date' -J y ":1. Signature, of Owner ,_,;,1
t WORKER'S COMPENSATIONDECLA ATION t
I hereby affirm ;under: penalty of perjury one of the following declarations:
(.) I have and will maintain a.certificate: of,consentto self -insure for workers'.
compensation, as provided•for by Section 3706 -of the --Labor Code, for Ithe
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 forwhichthis
permit is issued. My workers' compensation insurance carrier & policy no.. are:•
Carrier Policy No: '
(This section need not be completed if the permit valuation is for 1$1 or less):
(;•) 'I certify that in the performance of -the work for w.iich this permit is issued;
' shall not employ any person in any manne.rso as. sIto become subject to the
•workers' compensation laws of. Californi aA'agreei that if I should become
subject to the workers' compensation • oovislons of, Section 3700•of the Labor
.Code; I shall forthwith comply with provisions..
'
Date- Applicant
Warning: Failure to secure Workers Comp`ansation 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 attorneys 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 subjectpermit 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 authoriz�depresentatives.of this City. to enter upon',
the above-mentioned property fffo ah 466n purposes.Jf
dSignature (Owner/Agent) ,•r Date .
BUILDING_ PERMIT PERMIT#. :..
DATE VALUATION, LOT i+g TRACT .
JOB SITE
APN 'r
ADDRESS
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OWNER i'•
CONTRACTOR/DESIGNER/EN (NEER +
160 VNEACrRANDF,
l(i0 VWhhgT1!ATADU
LA CA 9225.3
1. Ai Qt.IIt'ITA I C lk 92253'
r3r:;0
;
USE OF PERMIT .•4-
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4 fw'ivmq�J '. 10,00 LF"
,XF1.04ATEO GY)ST OF COI TRt7L"7CZON
MaBTRUCT101I' FMI 101 d0€304,1 8.000 $54AW
TUTAL A. -XMU MM
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
N. _ .
•INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set cks
Underground Ducts
Fo2j & 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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-
Final
Final
F
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
gyp) ���
Electric Bond
Footings
I
Main Drain.
Bond Beam
_
cm
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
o l 3�
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)
-
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)