0205-106 (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
d=
Professionals Code, anmy License is in full force-and,effect.
License # Lia Class Exp. Date
I 11-457
Aate �' j f. Signature of Contractor
OWNER -BUILDER DECLARATION
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, 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; am exclusively contracting`_with licensed
contractors to construct. the.. project (Sec. 7044, Business & Professionals-
Co
rofessionals "
Code).
(.) I am.exempt under'Section B&P.C. for this reason.::'
Date Signature of Owner `y
WORKER'S COMPENSATION DECLARATION r.
I.here by affirm uncler,:penalty of perjury•one of the following declarations:
() I have and.will maintain a certificate of consent'to self insure fo'r workers'"
;compensation,. as''provided.for:by.Section, 3700'of.the' Labor Code; for the
performance ;of the worI6 r which this permit is issued.
Sec1 have and will maintain.workers' compensation insurance, -as required, by
tion 3700 of the Lab& Code, for -the "Performance of the work for which it is
permit" is issued. My workers' compensation insurance .carrier &'' policy no. are: .
;CarrierPolicyNo.. z.rU}e �1r li{}t133•F?�
(This section need not befc(impleted if the permit valuation Is for $100.00:or less).
( )' certify that in the performalie
nce of t:work for.whiclffhis permitis Issued,
I shall not; employ any person In -any mannerso as to. become subject to :the .
- workers' compensation"laws of California, and agree that`I I should" bec6nie'
ii
comply with those provisions.:-;;,,"
Warmng:.Failure .to secure Workers Compensatldn;.coverage Is unlawful and
shall subject an em
._,p cnminaf penaltjes'and civil flnes:up to $100'000, in
addition to the'postof compensation, damages as provided for in Section 37.06
of the Labor Code, interest.'and attorney's"fees.• #
IMPORTANT-"Application:is'hereby-madeto,the Directorof'$uilding 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 t .rte
PERMIT #.
WILD1NG,PERMIT -t�:�•
F
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS o,Tta.�}"rte. 1,1. C.}A.lFn. :Lf.J,J, p��3
OWNER
CONTRACTOR / DESIGNE.Rp/t EN &NEER
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USE OF PERMIT _
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RECEIPT
DATE
BY
DATE F NA LE
INS TOR
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
%� �(�a-- - -
Final _
—POOLS - SPAS
BLOCKWALL APPROVAL
— -
Steel
Set Backs
Electric Bond
-
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
_
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test —
_
Electric Final
Waste Lines
Water Piping
Heater Finai _
Plumbing Final
Plumbing Top Out
Shower Pans _
Sewer Lateral
Equipment Enclosure
G.K. for Finish Plaster _
Pool Cover
Sewer Connection
Gas Piping
Gas Test
Encapsulation
Appliances
^
Final - —�
COMMENTS:
i
--
Final i
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring _
Fixtures
_
Main Service
r Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)