0205-107 (RR)CA
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurythat 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
51)-1.57 C3`
;Date ""-' ;, Signature of Contractor
OWNER -BUILDER DECL-ARATION
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).
( ) 1, 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
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under-`enalty^ of, perjury, one of the following declarations: -
O :f: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:
(�) >have -and will maintain workers °compensation insurance; as -required by .
Section 3700.of the Labor Code.'for the performance of the workfor whichthis
permit. is,issued>My;workers compensation insurance- carrier & policy no. are:
Carrier t.Pd e Is;;atri ii `='Policy No.
(This section need not be completed if the' permit valuation is for $100:00 or less).
I.certrfy that in the performance of`the;.work for whlch`this permit is Issued,
IL §halt'not employ. any person in any m' anner so as to tiecomesubject to.the
Workers'. c6mpensation'laws of California, and agree that:if.l should become
subject .to the workers' compensation provisions of-Sectlon3700.of t le Labor
Code I shall forthwith comply with those provisions
Applicant .
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
ad_dition.to the`cost of,,compensat on,'damages,as provided for;in`Section_3706-
of the Labor Code, Interest and.attorriey'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 issuanceof such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state thatfhe 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 -•L"( �•.
BUILDING PERMIT PERMIT OV
DATE VALUATIONLOT TRACT
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OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
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USE OF PERMIT
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RECEIPT
DATE.- . j _
BY ?
DATE F NAL
IN SP CTO
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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
!l
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
I
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall _
Exterior Lath
Drywall - Int. Lath
_
Final a�o�-l�
BLOCKWALL APPROVALS
Fina!
Steel
POOLS-SPAS
_
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg Test
Fi� n.^.t
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
_
Waste Lines
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
_
Equipment Enclosure
Shower Pans
}
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances -��'
Fina!
.----
Fina!
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole T—
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures _ ~�
Main Service
Sub Panels
Exterior Receptacles
G,F
SmokeI.
Sk –�
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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