0205-107 (RR)LICENSED CONTRACTOR DECLARATION.
I hereby affirm under penalty of perjury that 1 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
5'T Cti 3, 9
,,.-Date `" Signature of Contractor
OWNER -BUILDER DECL--ARAATION
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 astheir sole
compensation,.will do,the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). .
( ) I, as owner Of the, property, em- exclusively contracting with -licensed:
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
• ) lam exempt under Section B&RC.. for this reason
Date Signature of :Owner, -
WORKER'S:COMPENSATION DECLARATION
I hereby affirm underpenalty. of perjury one of the following declarations:
O I have and will mairitain 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.
O_ .I have; and will maintain workers' compensation insurance, as required -by
Section. 3700 of the'Labor Code, for the performance of the work for which .this
permit is:.issued. My workers' compensation insurancer carrier &: policy no: are:
Carrier i.a.i: ,Ni?A; Ii Policy No.
(This sectionroneed not be.completed If the permit, Valuation is for,$100.00 orless).
O 1 certify that in the performance.of the.work'for which this;pe'rmit is issued,
f shall not employ any person in any manner so as to become subject to the
Workers' compensation laws of California, and agrewthat if I should become
Subject to the workers' compensation provisions of Section 8700.6f the Labor
Code I shall forthwith comply with,those provisions -,r' yy`
Date. Applicant 4'•• !' S -� '
Warning: Failure to secure Workers' Compensation coverage is unlawful- and."-
shall'sufiject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation,.damages'as provided forin 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 purposes.
Signature (Owner/Agent) •' Date -•
PERMIT #
BUILDING P=ERMIT
DATE VALUATION LOT TRACT
JOB SITEt� �., G
ADDRESS .B-✓'1.a,Dcl. 1.:3 �..'f'•> C f, .iJ,.f..•
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
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-EIPIANCEOEPT
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RECEIPT
DATE
BY
DATE F NAL
INSP CTO
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
-All-
O.K. to Wrap l v F.A.U.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
I
Fireplace T.O. Fans & Controls
Party Wali Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_ Final
Final
BLOCKWALL APPROVALS Steel
_
POOLS - SPAS
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
_
Underground P_lbg. Test
_
Finsl 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 Lateral Pool Cover
_
_
Sewer Connection Encapsulation
Gas Piping—
Gas Test _ r
'Appliances — T_
Final
COMMENTS:
--'
Fina!
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit ----------!!
Rough Wiring
Low Vcltage Wiring --
Fixtures
Main Service
Sub Panels _
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final _
Utility Notice (Perm)