0205-106 (RR)LICENSED—CONTRACTOR DECLARATION
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I hereby'aff irm- under penalty of,perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Divisi on 3 of the Business and
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Professionals Code, and my Licenis.Jin'full force and effect.
C) License # -Lic. Class Exp. Pate
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I.— OWNER -BUILDER DECLARATION
LU . I hereby affirm uncler,pbnalty of'perjury that I am exempt from the Contractor's
License Law for the following reason:
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Z 1, as. owner of the prop6rty, or my employees with wages as -their sole
compen§atioh,.,will do the . �.W
ork; and the structure is not intended or offered for
sale (Sec: 7044,, Business,& ' Professionals Cod6).
1, ;as'owner,iof -thb property, am- ex'Cl 6sively cont ' mcting,•witH licensed
contractors-•; - to congtru.ct t . he project (Sec. 7044,. Business' ..
&, Professionals
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ce) Section B&P.C. for this� reason
LO fam exempt under .�
Date 'Signatureof,Owner
Owne
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WORKEWS'COMPENSATION DECLARATION.
LARATION,
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l'hereby- affirrri under 'penalty -of Tperju"ry one, of the Jollowing
-declarations: cr:
0 1 have will maintaiir. dcertificate of consent to self-insure.for workers'
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Lij compensation, -as - provided -for" by Section 3700 of. the'La610'Code, for the
_J performan6e of the work fo'r which this permit is issued.
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.j- ave and. v�ii(, i�Bi "tin workers compensation insuia -n-ce, as reqiii(ed by
I work e f for which1his
0 Section -3700 of the Labor "Code 166"performance o ' the
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-pe workers e
_permit issued ker5 compensation,insuranc - carrier & policy. no :are:
Z 6arri6r '31'ATE FIM U Policy IVo. 011169700326i�
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<t (This section need not be-completbd it the permit v6iluati6n Is $100 00'or less)
_J O l.certifyihaiti6the -p?`
rformance of the. Work for whidh,,this permi0s'.issued,'
1 Shall. ribi.-e-mip"Iby any person in" any_m'aznn_er so as. to become subj6pt-to the,
workers' `compensation laws of Califorinia,; and agree that if lshoLild,9epqmp.,
subject 6'tk64orkeirscompensation. provisions of SeCii6-,W00 ;f 1l eJLajIbr
-.,1 Date: ,/., Code ,,l sh111 forthwithcomply with those" p`i�ovisions... ;i
tj V Applicant r.
.,Wa Compen�'dfi'�(h,unlawful
Inning Failu4ito secure Workers , c6verage.1s',
shalf subject an emplbyer to-criminall'penalties,and cMl7finles� - b'p'i $100,000, in
addition -' t ih provided foeinSection 3706
o e cost of-combensation, damages pro.
of,the-Labor Code, interest and attorney' .fees.
IMPORTANT Appli0aiibn is hbrky`ma& t6 the Dir6cto:"F`6f` Building and Safety
for a permit subject to the conditions and restri&tioiisset forth 'on,rhis
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 pe'rmit issued as a result bf,this BOO , ficaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta,-!its 'officbrs, 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 subje'ct 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,in , ppection Purposes:"
Signature (Owner/Agent) Date
PERMIT#
BUILDING PERMIT
DATE VALUATION' LOT TRACT'
JOB SITE
APN
ADDRESS <2Z
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OWNER
CONTRACTOR DESIGNER EN61NEER
OF CALD X.Z�U"A7 114'
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67 - 55 P",AIT" C 4",*(l,,-�t,'.',�l:"..'�I
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USE OF PERMIT
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CITY 0FLAQU, 'K
FINANCEPEPT.
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RECEIPT
DATE
BY
DATE F NALE�
7
INS
TOR
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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 i
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 i
Party Wall Firewall
_
Exterior Lath
Drywall - Int. Lath
Final
Final
_
%I C�a— _
POOLS - SPAS
�
BLOCKWALL APPROVALS
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
Heater Final
Water Piping
-Plumbing
Plumbing Final I
Top Out
_
Equipment Enclosure
Shower Pans
G.K. for Finish Plaster
Sewer Lateral
Sewer Connection
—� —
Pao; Cover
Encapsulation —
Gas Piping
Test
Gas Test
Appliances
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— —
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Final w
Final
COMMENTS:
go6"
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
i
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)