0205 114 (RR)LICENSED CONTRACTOR DECLARATION
Vj 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
UJI Professionals Code, and my License is in full force and effect.
0 CY) License # Lic. Class Exp. Date
C) Lr)
7
LU r—
r
Z r— 15ate Signature of Contractor
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_J Po OWNER -BUILDER DECLAAM ION
(-) CO
U LU r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a- License Law for the following reason:
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Z 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 & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co I am exempt under Section B&P.C. for this reason
LO
C\J Date Signature of Owner
0 C\1
< WORKER'S COMPENSATION DECLARATION
2 < Z < cr 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'
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< UJ � compensation, as provided for by Section 3700 of the Labor Code, for the
_J < _J performance of the work for which this permit is issued.
—1
< 0 1 have and will maintain workers' compensation insurance, as required by
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LO <ection 3700 of the Labor Code, for the performance of the work for which this
0) permit is issued. My workers' compensation insurance carrier & policy no. are:
`t Z
ob Z) Cartier Policy No.
< (This section need not be completed if the permit valuation is for $100.00 or less).
_J ( ) 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 provisions;,
Date: 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
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 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
Signature (Owner/Agent) Date "I
BUILDING PERMIT PERMIT#
DATE C VALUATION LOT TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER INEER
.A-' A(
l_A CY04341A
6 (7A $i
USE OF PERMIT
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CITYOFLAQUIRTA
FINANCE DEFT
RECEIPT
ATE
BY
DATE FY4ALED/
INSPECT(?A/
e
it
O l W
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
r
Steel
_
Combustion Air
_
Roof Deck
�p��f�
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
i
Drywall -'Int. Lath
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Final
Final
_
_
POOLS -SPAS
BLOCKWALL APPROVALS
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steel
Set Backs
Electric Bond
Footings
Bain Drain
Bond Beam
Approval to Cover
_
_
Equipment Location
Underground Electric
_
—
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
_
Electric Final
Waste Lines _
Heuer Final
Water Piping
Plumbing Final
Plumbing Top Out
Shower Pans
Equipment Enclosure
O.K. for Finish Piaster
I
I
Sewer Latera) _
Pool Cover
Sewer Connection
_
Encapsulation
Gas Piping –
Gas Test
Appliances
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Final
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COMMENTS:
W
Final
Utility Notice (Gas)
• ELECTRICAL APPROVALS I
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)