0205-100 (RR)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
,A5ate. Signature of Contractor
I hereby -affirm under'penalty of perjury that I am exempt from the Contractor's
License4-aw 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 Code).'
1, as owner of the, �Oroperty, am -exclusively'contrkting with licensed.
contractors to construct 'the- project '(Sbc. 7044, Business & Professionals
I- am,exempt under Section BAP.C. for this reason
Date Signature' of; Owner
WORKER'S COMPENSATIOWDECLARATION
I hereby aff irm under penalty of perjury one of' the folldwing,_0eclaration§:
),I have,and . Will . maintain. a certificatidbf cons 6nt to self- - in sure for workers'
compensation, as provided for, -by Secti'on.3�0'0-oi-.the Labor Code, for the
parf rmanc'e of the work -for which this'permit is' is s�Lied.
I have and,will �naintain workers' Compensation -insurance,.Bs required by
S, c ion 370.0. id "the Labor Co"de, for I the performande.'of.the work for -which ".this
Camer JA ;,'TAf11lq0 Policy No
(This section need- hot be completed if the-pdrrnit valuation is f6r. sikoo pr!qss).
I certify the in the, performance of the S 'd:
work for;which this permit I issue
1. shall not e rnliiploy any, person, ir..any manner so- as to become _.�ubject to* the
�subject'to the'workers� compensation provisions, of Section 3700�of'the, Labor
e Applicant
6: Failur
addition to'the cost of compensation, damages as provided for in Sktioil , 3706
of the Labor Code,,interest and attorney's fees.
'.IMPORTANT* Application is hereby made'to the'Director-of Buildinq and Safety
1. Each r person. upon whose behalf this application is made & each person at
whose request and for whose benefit work is pqrf(?rmed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quintp, its officers, agents and employees.
2. Any permit issued as a result of this a6plication becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 18.0 days will subject permit to cancellation.
I certify that | have read this application 6nuutate that the above information is
vonoo. / agree mcomply with -all oxy, and State laws relating mthe building
non City menter upon
^'~above-mentioned property '~ .^
~
Signature (Owner/Agent) �� Date'
BUILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS
�APN
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
P.
USE OF PERMIT
RECEIPT
DATE
BY
IDAXIld
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
i
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
I r
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
s
Drywall - int. Lath
_
Final
I•�L.�`
-�
—�/���
- ; '..�
BLOCOKWAI,L. APPROVALS
G----
! sef Backs ;
c_cctric F._
!
F01-r7t4e ;
"flair, sir,
. __---
oo,^ Beam --
ADnrc,a—
_r
!_
MU.- Piz,- Les.
Fir}a
!.a-.
PLUMBi,JG APPROVALtia
naWaste
Lirqs 4
Water R'..ng
---
, P rn ng TOP Our ----------- I
- -
IY ..e Pans-
'e, -.-erLa:-ral
c ,
5i ew Onnfo
N r
_
I Gas ?ip; f ;
-
was T_'-st
Hnm
Utilr": Na lice (Gas) { �
ELECTRICAL APPROVALS
i 'i ennp Power pole
Underground Conduit,
Rough, Wiring - ;— ---- ----i
;_ow Voltage Wiring - ----
Fwtures !
Ma n S--rvice _ --
Sub Panels—_`---�- -- — ----
�r.:<;enorRecePtasles
-
G F.I.
`..moke De°cctors----
- -- —;
'; ern.. Usa of Power
—
--
I Final
Utilrt Notice (Perm) ��