0111-002 (RPL)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
Date `r''` `' r 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:
( ) 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&RC. 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 3"T,N1'+u;N31.1ri Policy No. J61'07A-�3
(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
Code, I shall forthwith comply with those provisions.
Date: .• I .. 4: ApplicarlIL —
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 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 for inspection purposes.
Signature (Owner(Agenf)— J_ - Date,-
PERMIT#
BUILDING PERMIT
0111_00
DATE ` VALUATION s7ror '.fo LOT TRACT
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APN '
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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(76Q)1277 97.
USE OF PERMIT
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FEE { 01-(.bt3d: _418-000 $207 00
P-11:31.1 1011,800E421-000 $2400
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RECEIPT
DATE
BY
DAB F F}L D ^
INSPE
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs
I
unaergrouno duds
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
RoofDeck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party v I;;Il Insulatinn
I
Condensate Lines
Exterior Lath
i Drvwall - Int. Lath
Final
SLOCKWALL APPROVALS steel
Set Backs Electric Bond L
Footings _Main Drain j
Bond Beam Approval to Cover
Equipment Location
Underaround Electric
Final I [ Gas PipingQ(—
Gas Test
UrL SING APPROVALS Electric Final
Waste Lines Heater Final
ater Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K. for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation O
Gas Piping
Gas Test
Aonliances
Final
COMMENTS:
Final
Utilitv Notice
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp, Use of Power I
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OF LA Old J NTA
IlDiNG & SAFETY DEPT.
PROVE
FOR CONSTRUCTION
DATE - -D / gym^