0205-107 (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 full force and effect.
License # k Lic-Class Exp.. Date
n ,{
Date G. t Signature of Contractor
OWNER -BUILDER DELLAATION
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).
). a, 'as 'owner of the property, am. exclusively contracting with licensed
contractors to construct the project (Sec.. 7044, Business & Professionals
Code).
O 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 Tof the following declarations:
c.), I 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 permlt is issued.
-.(�)i Fkave,and will maintain workers' compensation insurance, as required'by
;Section 3700 of the Labor Code for the 1.performance of the work for which this
permit is Issued., my workers' compensationrrylnsarance:carrier &:policy•.no.,dre: '
Carrier
(This section:need 7notJbe completed; if the;;permit valuation is for $100.00 or less).'
(, ). I certify that'in.the performance of the.work for which'this permit is issued,
I; shalt not'employ any person,Jp any manner.'so as to become Subjectto.the
w61rkers;:comperisation laws of: California, and agreethat: if I should`�b'ecome
sUbiect_to the workers' ,compensation provisions of §ection 3700 of th'e' Labor
-Code I shall forthwith comply with those provisions r. r �`
:Date � ;�� .Applicant - -A• •• •' .�� r
'. Warning: Failure.to secure .Workers Comp nsation-coverage is<unlawful,and
shall subject anemployer to criminal 'penalt es and•civil:fines up to $100;000, in
addition to the cost of compensation, damages as provided,foi in Section 3706
of the Latior Code`" interest and attorney°s fees. x
,"IMPQRTANT• 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 -Pr 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.l have read this application and state that tete 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) ° >'k '` Date r b
PERMIT'#
BUILDING. PERMIT
DATE _ �` VALUATION bra!-y�<S4.Li LOT TRACT
JOB SITE y' — /
ADDRESS
/
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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F.S:: 1"ilkt tr.r cft?'t:1'4c'�j i:.,743:,i:t;�f3 r��!,.,:i�wl'i'.
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USE OF PERMIT
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CITY OF LAQUINTA j
PINANCEDIEPT_ _.
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RECEIPT
DATE .., /
BY ?
DATE F NAL
IN=
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 "��� 2
Exhaust Fans
O.K. to Wrap 111 v
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 7�'f %a--
Final
_
POOLS-SPAS
SLOCKWALL APPROVALS
"
Steep
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg, Test
Fina[
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 Plaster
Sewer LateralEEH!E!nc
l Cover
Sewer Connection
Gas Piping
apsulation
I Gas Test
Appliances —_
I
Final
COMMENTS:
r Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring v
Low Voltage Wiring
FixturesMain Service
,
Sub Panels
j
Exledor Receptacles
d
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)