9611-008 (AR)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 # r Lic. Class' Exp. Date
uDate Signature of Cc ntractor
OWNER -BUILDER DECLARATION ., r
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 soje
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 (Seca 7044, Business' &' Professionals
Code). •, '
O I am exempt under Section B&P.C. for this reason'
Date Signature of .Owner- '.. • i
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. .
Y' 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, t& 'policy. no. are:
Carrier Policy.No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
C de, l all forthwith comply with those provisions
y.� ��{ (!
ate:
Applicant—' re. , Alii. >iC.t_U
V .. dr
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 orpursuanYlo,
any permit issued as a result of this applicator agrees to,4 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 cancellat'
I certify that I have read this application and state that the above informatio i
correct. I agree to comply with all City, and State laws relating to the buildln,
construction, and hereby authorize representatives of this City to enter upon \
the above-mentioned property�for inspectio purpolses.
• Suture (Owner/Agent) t t x •� l 1 Ak�d Date �� 1
• '-BUILDING PERMIT ' PERMIT# . °°NTR°`"
4284
DATE: ��6M6 VALUATION 91 y b a LOT, TRACT'
JOB SITE
ADDRESS '. ...'47itf^•:rt�S� .CLDi:�r.�.. 1t9�i..,aA.L.` - . - r'
APN
OWNER -
CONTRACTOR/DESIGNER/ENGINEER
• L'::� ��1L'�'�t,:T'i�i7•t�1' .
�a�.�t'1'1 CI°� �t1;1%�3CtS
.50-000 i'1✓iig 8k;AC,1.t .. ..
52711 Vi:3:,AF CO ' %. °->
1. A(AAN°! A , CA 9225:
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tts 9 j �1-1::t19 CC sR, WI 40
USE OF PERMIT.
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.411<AN C7.1`FCJ J7.Ff 3.18 $40.95
'# I'i t Xi Rg011014 :H GRS,- #?:4%0 •,i 01A)00-24 1 -000
T_1331'0`YXL f''ON "IRUC'e ON AND Pt..P.P CHECK
'$120L25
$11.00
i t E+►�a �� FEre DUE NOW..
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ECEIPTDATE
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
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
POOLS - SPAS
BLO KWALL PP OVALS
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)
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)