0002-108 (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 force and effect.
License # Lic. Class Exp. Date
� f 1
Date ' r(.)t7 Signature of Contaactor
OWNER -BUILDER DECLARATION i
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 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 (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 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 r a •r• . ».0 b Policy No. rya rrn
(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-fer- v hich 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 bor
Code, I.sliali fgithvyj, comply rith those provisions.
Date: Applican-• ��_.
Warning: Failure to secure Workers' Compensation coverage is unlav&l and
shall subject an employer to criminal penalties and civil fines up to $1001000, 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 with.all- ity, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above -mentioned property for inspe4ti i putpo�s s,
Signature (Owner/Agent) Date
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r BUILDING PERMIT PERMIT#f44}1;t'-�415i
DATE VALUATION 'f+>'.y�D9: +?,t14P LOT ) TRACT 29"Yoh
JOB SITE 4 i 463 VISTA CALICO
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ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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1.A QUHN-I'.A i-A 97253
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RECEIPT
DATE BY
DATE FINALED
INSPECTOR
f'..._ 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
OK to Wrap A F.A.U.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall 10
Exterior Lath rr /
Drvwall - Int, Lath te,
Final
BLOC
Set Backs
Footings
Bond Beam
Final
PROVALS
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Final / L2LI'/
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 V
Temp. Use of Power
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Encapsulation
Final
COMMEN"'S:
PAS
Final
Utility Notice