9907-418 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I amilicensed 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
Jr
ater Signature of. Contractor�`�
OWNER -BUILDER DECLARATION-'.-
I
ECLARATION '
I hereby affirm under penalty of perjurythat 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 & Prof essionals Code).•
( ) I, as owner of the ;property, am exclusively contracting with licensed
contractors to. -construct the project (Sec. 7044, Business & :Professionals,
Code):
( ). 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, -as provided for by Section 3700 of 1he. Labor Code:- for :the
performance of the work for which.this permit is issued.` '
( ) l have and will maintain workers' compensation' insurance, as s required by
Se6tion 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.
-iJ L/'k.6 �>1' 1.1/,tiM' _ •:14U 7•-�h�-tfi./V/:�.t �^+'
(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 as to become subject to the -
workers'compensation laws, of California, and agree that if l should become
subjget to/the workers' compensaUo�nyppvisions of Section 3700.of the Labor
Cg e.)/S all/�9 `hwtf� omplywith the e proyisiorSs, /I
,Efate: "� C'�E'/ ppllcant�%(.r</` f ;
Warning: Failure to secure -Workers' Compensation coverage is unlawful„and
shall subject an employer to criminal penalties.'and civil fines -up to:$1o0,000; in
additionto the cost ofcompensation, 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 .ofsuch
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 inspection purposes
7b
i,Signature (Owner/Agent)-t—; Mw Date
PERMIT #
BUILDING PERMITy�p.
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DATE VALUATION iic1.i8w�1 6 �� 'LOT , g3 : TRACT 259JOB
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ADDRESS %'�t•�2�N9 CAIL�+Y VD.•�•I:A VER -OR '� S � .
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OWNER
CONTRACTOR /DESIGNER
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PAUMDESEU CA 02211
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USE OF PERMIT
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3.33ATaR RINGS FE.3 !Q�-�ir9f�-�ta�•f�(�i? $�,ll
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
— — lei
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
_6 40
Compressor
Insulation
Z _ f . 9 164
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
2 —. -cm
Drywall - Int. Lath
7--
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
9 8-F 9 r'1:.L
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
.Sewer Lateral
_ �i , a
Pool Cover
Sewer Connection
�tJ
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
Utility Notice (Perm)
COMMENTS:
C