0205-109 (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 fu * 11 force and effect.
License # Lia Class Exp. Date
-"bate Signature of Contractor
OWNER -BUILDER DECL:ARAT16N
I hereby affirm under penalty of perjury that I am exempt 'k from the Contractor's
License Law for the following reason:
1, 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 &,Profess i6nals.Code).
1, as owner of the-i5roperty,-Am exclusively contracting With licensed
contractors to construct.thei oroject (Sec. 7044, Business & Professionals
Code).
O I am.exempt under Section B&P.C. for this.reason
Date —Signature.;of Owner
WORkE . R'StOMPENSATIOWDECLARATION'
I hereby; affirm under penalty, of. pprjury one..of the following declarations:
have and wJl1,nia.int_ain,..a Certificate of,consentlo,self-insure for -'workers'
compensation; as provided for by° Section 3700 of the Labor'Code, for the
performance of the workjforwhich� - this perm . it is issued.
I hd4and will ,maintain ,work6rs':compensation insurance, as.req6ired by
.s.cctibh 37.00- of. -the Labor Code for the- p6rfoom an.Pe. of the work for which this
`permit is. issued. My workers' .compensation insurance carrier & policy no. are:
6 I -P if Policy.Nd'. 7
JND _II4V5A1J;f.J
(thi_§ section need not be completed'if -the: permit 4uation. is for $100.00.6r less).
Tce rtifythat. in the performance of the work for which this permit is issued,
I sh all't n ot 'e -m .ploy any p er . son -i - n any manner s'6 as' to become subject to the
Workers Compensation laws"& California; and agree that 'if I shouldbecome
Subjtto W
ec 4�:�' 6'rke4 compensation provisio , ns bf.,Sedon 3700 of the Eabbr
. ,
'Code, f shall forthwith comply with those'provisioh
Date: Applicant -
Warning: FaiilOre to secure WbrkersCompensation coverage is unlawful and
shall subject an'employerto'criminal penalties and civil'fines up to1100,000, in
addition to the cost of compensation, damages as provided forJn Section 3706
of the Labor Code, interedt-an6attorney's fees.
IMPORTANT Appiibaition'is'Aereb' -to t6e.Dif6cibir of Buildini'
y made g 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 orpursu5nt 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 Jssued 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/Agent)
Date
PERMIT PERMIT#
/BUILDING
DATE VALUATION LOT TRACT
J
JOB SITE
ADDRESS 15 0AX 6_01,L 521
APIN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
J) (Mi," 3 Cju
P. Do (,XX 106()
CfiXY0YH 1).R1V11',
l..A Q0`134TA
CBIU!
USE OF PERMIT
R1?JVJQV1#HT'1 C1,AQ1A`0' A.
44 . 1,41.. V4 I V AK P I 11. 1
V x'1;:1.1 � I1(.1/4
("-`CMC f"A"P %10!1-19115N.R. T
Q UY0
p, Lllk!
01 8-000
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kiAl Q
CITY OF LAQUINT
FINANCEDEPT
X.)B 1.1, YE
I.10.00
VJTAL 1"ER.hPil 711F'ET�; 3M Y NK)"A'
4
RECEIPT
ATE.,
B' Y
T
DATE F1 LED
INS TOR
PC
. -
77
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fd
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING_
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
O.K. to Wrap
_ _
{p�� 2—r�
'
Combustion Air
Exhaust Fans
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
Drvwali - Int. Lath
Final rJ((Oa--
BLOCKWALL APPROVALS
Final
_
POOLS - SPAS
Steel
Set Backs
_
Electric Bond
Footings �,
Main Drain
_
Bond Beam
Approval to Cover
_
Equipment Location
– 1
_
Underground Electric
Underground Plbg, Test
Final
Gas Piping
PLUMBING
APPROVALS
Gas Test`
Electric Final
Waste Lines
heater Final
Water Piping
_
Plumbing Final
�
Flumbing Top Out y
Equipment Enclosure
— �—
Shower Pans
OX for Finish Plaster
Sewer Lateral
_ T
—�
Pool Cover
Sewer Co; nection
_
Encapsulation
_
Gas Piping --}--
Gas Test I
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 Recaotacles
G.F.I.
Detectors
_Smoke
'Camp. Use of Power
Final
Utility Notice (Perm)
L"