0205-109 (RR)LICENSED CONTRACTOR DECLARATION.
I hereby affirm underpenalty.of perjury that I'am licerised 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 _ Signature of Contractor
... ACJ ...a� ..
OWNER -BUILDER DELL=ARATION
I hereby affirm under penalty of perjury that.l 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, Busines"s & Professionals, Code).
( ) I, as owner of the property, am exclusively contracting with licensed
Contractors to construct the project (Sec. 7044, Business & Professionals
.Code).
(J 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 maintainta certificate of -consent to -'self -insure for workers'
:compensaiion, as, provided -for by 'Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
have 'and will main tBin 'Workers' compensation .insurance, as required by
S 6116n 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:
Carrier4: f �?, j ,. }�t J i j f;, Policq No.
" = (This section -need not be completed,if the; permit valuation:isfor $100.00 or less).
O 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' cornpensation provisions of.', Section 3700 of the Labor
�. Code I shall forthwith comply with those provisions
Date. Applicant' • rr
r
Warning: Failure to -secure Workers Compensa ibn�overage Is unlawful and
shall subject'an employerto criminal penalties.andcivll 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 tFie-Director`ofBuilding 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, w 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/Agent)`', -' �r ? Dater_'=
PERMIT#
BUILDING PERMIT
01X'►5_ 109
DATE • j VALUATION LOT TRACT
JOB SITE ADD ESS �`L.fnu)f.%.'J.r'.' 6.}./i.t�.'e.f.i.,L !�f — /33
APN
OWNER`���
CONTRACTOR / DESIGNER / EN (NEER
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USE OF PERMIT
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CITY OF LAQUINT -`
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RECEIPT
DATE- '
BY
DATE FI LED
INS TOR
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
�OT) 2 �_
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
Drywall - Int..Lath
Fina! �f _Ia��a--
BLOCKWALL APPROVALS
Final _
POOLS - SPAS
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 _
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Co .rection
—
Encapsulation
Gas Piping
Gas Test
Appliances
Final —4+---
--
COMMENTS:
1
'
J
�^---
—
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough hang
_
Low Voltage Wiring
—
Fixtures
Main Service
Sul Panels �!
Exterior Receptacles
G.F.I.
Smoke Detectors _
Temp. Use of Power
N�
Final _
Utility Notice (Perm)