0109-141 (RR)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
Ty 094 0 CIS 9 MC 11130101
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:
( ) 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).
</J 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 n
3
Date 0 /. r 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 Policy No.
STATE 1UND 20-0.0-0019"
(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 provisionl.
Date: F> 0. r Applicant—
Warning:
pplicant 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 hate 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 purposev.
Signature (Owner/Agent) t,./rf 1��• �� ad r3 t/ Date 0 . r
�
J/BUILDING PERMIT PERMIT#
DATE �I :i VALUATION LOT 0+109_141 TRACT
3
OWNER
CONTRACTOR/DESIGNER/
APN
LA.QKIRUA 17P71WO CA ! Z201
(Y60347.9M9 C1IX 5978
USE OF PERMIT
RE-ROCIPWI H CLtA.S` a A .t1.A'POC9ALS- 81,,0 90.5 t;
044101, W-495
VALUATJON
11500.00 6q
Enn"rED COW OF CO1`dS'JCA UC.111,70N
PFAWIIT PIS SUr, y
' 1K00F FEE � 161-000-438-0,00 $10,90
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TIMA r FUMV FPW L?$79 ,NOW
RECEIPT I DATE / I BY I DATE FINALED
INSPECTOR
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$30.00
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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
i 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
Final161Y
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
; Electric Bond
l
Footings
Main Drain
j
Bond Beam
Approval to Cover
Equipment Location
j
•. Underground Electric
1
I Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
i 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
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: