0205-108 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed
d under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code,'and my License is i,h-'full f6rce and effect.
License # Lic. Class Exp. Date
J 9
. .........
Date Signature of Contractor
OWNER-BUILDER!DEC _ LAWION
I hereby affirm under penalty of perjury that I am exempt 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, willtdoffie work, and the structureis not iritended or..offered for
sale (Sec. 7044, Business & Professionals Code).
1, as owner of the property, am exclusively contracting with .licensed
contractors to construct ..the project (Sec. 7044, Business & Wofessiolhals
Code)7
O I aiTI-exempt under Section B&P.C. for this reason
Date Signature.' of Owner
WORKER'S COMPENSATION DECLARATION.
3-Ity of perjO ey one of the following' declaration 6:
1 hereby affiri�fi,16er- penalty
I have and will 'maintain -a Certificate of consent to'self-insure for workers'
compensation,, a 9,provicl6d for -1 by Section. 3700 'of the Labo'r'tode, for the
performance of the work for which this, permit is issued.
maintain aintain worlke'
I have and will 'r's_``compensation insurance, as required by
Section 3700 of the Labor Code„ for the perforriiance'of the work for which, this
,permit is issued. My.workers'!compdns'ati-on"in-suranc . e carrier &-policy no. are:
Carrier ----h, ' - ° P61icy No. 1 0 6.,
(This section need.not be completed if the permit valuation is for $100.00 or less).
4( 1 certify that in*the performance of the work for which t.his;.permit is issued,
"not, employ any. person - lin any.manner s . o as tobbcoefie subject to.,the
.1 shall
workers' , _comoensati'on - laws'of`balifornia, and agree. that if I 'should bec6riie
subject to'tiheworkers' ' provisions of Section .3,700 ofthe.�Labor
. s .......
,eode, T�H�Jli forthwith comply,with those p�qvis6�i.
DateApplicant—
Warning:, Failure to secure,Wfdrkers' C_'om_p'-e�n_Zti6n coverage it unlawful and
shall;sdoject an employer to crlminal°oenalties and civil fines up to $100,060, in
addition to.,thebost of "compensation, damages as provided for in Section, 31,06
of the ,Labor Code, interest ancl.'attorney's fees.
IMPORTANT, Applicafion 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 purpose
Signature (Owner/Agent) Date,'
BUILDING -PERMIT PERMIT #
DATE VALUATION LOT TRACT
JOB SITE =
ADDRESS IXIAD(`L 1.1 0A.K.113.1KII,
777
APN
OWNER
CON/TRACTOR/DESIGNER/EN 1NEER
Fm, 42, WESTRR-,�JUE Ho
U." 16i M., ' 1 +53'J1.fi.1 D
67 - "i 5 EA�M)._' PAIUM. VE,
C -A
Z714
.USE OF PERMIT
.3 T1 fAfILD. C
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P i-ROCIF-WIT19 CILAo x.
F I tV) (IRNT UP :I SS'.'n 7,K 0.N
RE-ROOl" Yff" IN 000 "_1_000tit .P9
[ViAy Lill
CITY OF LAQUIN'TW.
F1MftHCEbE
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RECEIPT
DATE
BY
DATE FILED
JINSP
I -ECTO2
sf,
&.
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
_
O.K. to Wrap
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
_
Final ���/� %
BLOCKWALL APPROVALS
Final
4
POOLS - SPAS
steel _ 1'
Set Backs
Electric Bond
Footings
_
Main Drain
Bond Beam
Approval to Cover
—'
Equipment Location
Underground Electnc
Underground 2lbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
_
I Electric Final
Waste Lines
_
Heater Final
_
Water Piping
Plumbing Top Out
Shower Pans —
Sewer Latera:
Sewer Connection^�
Equipment Enclosure_ —�
OK for Finish Plaster
Pool Cover
s Encapsulation
COMMENTS:
r
j
Gas Piping
Gas Test
Appliances
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)