0205-099 (RR)�,�. �..u�u vVl•, �IhV 1 VI', \lLV LMIIMI IVIV
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 N Lic. Class Exp. Date
Date Signature of Contractor r "
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that'f-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 & Profes'sionals Code).
( ) I; as owner of the,property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code) .
O I a.m'e_xempt under Section B&P.C. for this reason
Date Signature of -Owner'
WORKER'S COMPENSATION„DECLARATION
I hereby'affirm'Underpenalty•of,perjury one of the following declarations:
O Ihave and will maintain atertificate of consent ;to self, insure for workers'
compensation, as provided for= by -Section 3760'6f the.' Labor Code; for the
peiformance,of the work for.which thls:permif-is issued. _
Have:and will maintain workers' compensation insurance, as required by
Secfion 3700_of ttie Labor Code, for the: performance of the work for which this
permit is issued:; My workers' cornpens'ation insurance carrier &•'policy no.: are:
Gamer t, ii -policy No.'
' 1 f i�:lf �' .-{!�, {M1. �. �`• 11.i�.ti) 1 {i t; l(�iY:i
(This section need.notbe conn pleted. if the permit valuation -is for $100.00 or less). .
.)� I certify that in+the performance,of the,work for which this permit is issueii,
I;shall'not employ any- pe.rson In any manner so as to become subject;to the
Workers' compensation laws' of.California, and agree that if I, should become
subject to_the workers' compensation_ provisions of Section,3700-of the Labor
Code; I shall forthwith.comply with.those provisions.
Date:' :Applicant
i
Warning Failure tosecure WorkersCompensatlon`coerage, is unlawful and
shall. subikit-an employer;to criminal penalties and•civiHines up to$100,000, in
addltlon,to the cost of compensation;' damages as:provided'for in Section 3706
otthe LaborCode, interest<and attorney's fees:
IMPORTANT! Application is hereby made to*the Director of Building and Safety
.,.for a ,permit. subject,.to. the conditions and. -.restrictions :set' -forth on --his
;application.
1. Each person -upon whose behalf. this application is made & each person at
w:iose request'and for whose benefit work is performed under or pursuant to
any permit Issued as,a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify.that I have read this application and state that the above information is
correct: I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date.-
BUILDING PERMIT PEHMIT1f
DATE % dALUATION LOT TRACT
114 414 W
JOB SITE'
AP_N
ADDRESS J$.,.��Q? :?�F,r�!ai.�A•.. ✓T li�
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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r4a:ri 11. Vt C1 C), ��13:1_i::9 1) 01,' I :I f?its IIA, IM'_'
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USE OF PERMIT
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3't i:l:i• : 1 601'4)A1�. ::il4— .
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OF QIDINT�
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RECEIPT
DATE " !
BY,
DATE FI A
INSP C O
D
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
bents
Fireplace F.L. !
Grills
i
Fireplace T.O.
Fans & Controls
i
P2 -;y Wall Insulation
i'arty
Condensate Lines
( _
Wall Firewall
I
Exterior Lath
_
Dr}wall - Int. Lath
/¢` _
POC3 - SFAS
ELG rKWALL A
Steel —
—
SE: Ba3ks
Electric Bond
Footinc:s i (
Main Drain
Sang' Beam i
Apprc:al to Corer
-�---
Ecuip.T.en: i ncatmn
_
I
Unde- ound E-lect!ic
-
--- -� --
I (_ —
Unoerpr4und P!tg. Test
F Fina!
Gas Pining
I'L4JI�� IS�IG APPROVALS Gas Test
--
Electric F,; -.al
aivtaste
v4aste Lines
weate. ',na'
_
7';V- Piping ( jium!,tr
i`inal--
—
Plumbing Top Out i --
s_q_zmen - '
— _ --
_
^wee r Paas 1 i
:c. fornis,
� P `I Piaster
1
_—
_
;
ra ier Lateral 1 —
I'=
l:Cnnestion - I - - i --- - - i
C2n
Gas Piping `� •I _.,._ f—
--___._- _--_
� — ----
Gac Test�-----
Appi ancec _ —_ _ _ — -- ----�_--.----
N TS
-
Utility Noiic= (Gas)
ELECTRICAL APPROVALS f
Ternp. Power Pole
Underground Conduit T—
( Rcugh Ming
I Low Voltage Wiring
Fixtures .
Main Sery ae
_j
Sub Panels ----�
Exterior Receptacles ! I1
G.F.I. -- I
j Smoke Detectors —
Temp. Use of Power
r
Fina,
Utility Notice (Perm)