0205-101 (RR)1 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 # Lic. Class Exp. Date
Date— Signature of Contractor <,."s XT
OWNER -BUILDER DECLAAATiON
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).
( ) I, as owner of the property, am- exclusively contracting with licensed
contractors, to construct the project (Sec. 7044, Business A Professionals
Code),
O I.am exempt un.6er'Section B&P.C. for this reason.
Date . : signa(ure of Owner
WORKER'S COMPENSATION DECLARATION
I hereby. affirm' :under penalty of perjury one of the following declarations:
( ):'I"have and -will maintain °'certificate of consent to self -insure for workers'
compensation, as provided for by -Section 3700of the Labor.Code, for the
performance of the work for which this permit is issued.
�(') l have and will maintain workers' compensation insurance, as required by
Section 3700 of the,La66r C—C e;'for the performance "of the work for Which'this.
permit is issued. -My workers', compensation'jnsurance•carrier & policy no. are:
Lamer t PolicyNo.
(This section need'hot be completed if,the permit' valuation isfor•$100.00 or less).
( ) ,I certify that in the;perforrhance' of the work for which this.permit is issued,
=1 shall not employ any person •in "any -manner so.as'. to become "subject, to the
°workers' compensation. laws. of CaliforrSia, and agree that if: fahould.become
subject to the:worke'rs'' comp'ensation:provisions of Sectio n, 3700;: of the Labor
Code I. shall forthwith comply with those provisions.
;,-Date F`+''e' Applicant.
Wanling; Failure. to secure Workers' Com ensatioWcoveJ
rage is.unlawful and
shall subject an employer to criminal penalties and"civil fihes up to$100,000;-in
addrhon 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,,. r
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_
BUILDING PERMIT
/
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS S3 ta1.1.}h3. �3ar.t•_ �S
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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j.:,A. 1? 1j`j l',y
i..4 ..'i:;:.f lt?.'t.i. C:'t'i..�• `./,�':.r '�
USE OF PERMIT
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RECEIPT
DATE
BY
DATE FIN D
/ p
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DAZE 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 Wa!I Firewall
Exterior Lath
Drywall - Int. Lath j
I
_ I
_ _ Final
Final '10�1� Q --�
BLOCKll ALL APPROVALS Ste. -I
POOLS -SPAS
Set Backs o
J Electric Bond
Footings
1 Main Drain
Bond Beam. 1
- i INDproval to COVE.'
Eq,j;p;nent Location
�—
Uneergroun3 E:ecrric
--r
i Underground D:Dc. Test
Final
Gas Pip;^g
PLUMBl€4C APPROVALS
ectric Firs:;:
Waste Lines j ___ �FL_r Final _
L�,'3ter ?!ptn; --�5 --- tlb; 1� Final
--
j
—
j
Plumbing Top Out_�
Shower Pans�P{o
Sewer Laic a'. -+
r—_�—
SSWef
Gat Piping—
Gas Test—
te,
--- P.O-c. t,ov-.
— — -
---
'----
pplizn ,es i
I
' Fina:—___-�_—_—.—"_---.—.---�
Uti;cy Notice (Gas; i
--
i ELECTR6CAL APPROVALS �
em^. Power Pole --�—i
Underground Conduit
rRough YNifing
� --
! LYv Nonage Wiring
Futures
—
Main Service
! Sub Panels—
Ex,e;ior Receptacles
G.F.I.
Snoke Detectors
Temp. Use of Power
Final j
Utility Notice (Perm)