0002-016 (SPIN)LICENSED CONTRACTOR DECLARATION
,.1 hereby affirm under penalty.of,pe'rjury that I am licensed under provisions of
.
in-
-Chapter. (commencing. with Section 7000)`of Division-3 of the Business a_ nd
`Professionals Code,'and my License'is iri full force and effect.'
' License # ' tic. Class Exp., Date
"Date Signature of Contractor
;A..
OWNER -BUILDER DECLARATION
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 emplo.ees.with.wages as their sole
_compensation, will do the work, and the-strubtukis'not intended or offered for .
sale (Sec. 7044, Business & Professionals Cocfe).
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.. 7044,• Business & Professionals
()%I am exempt under Section B&P C. for this reason,
ate Signature of Owner.+. 7,i"' 1
WORKER'S COMPENSATION DECLA ATION
1 hereby affirm under penalty of perjury one of the following declarations:.
( ) I have and will maintain a certificate of consent to self -insure for workers'
,compensation, as -provided for by Section 3700 of ,the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance;,as required by
Section 3700 of the Labor Code, for, the performance of the work for which this
permit is issued. 'My workers" compensation insurance carrier & policy no. are:
Carrier Policy`No.�
RE<DLANDS INS. CO.1-510V1^}134
(This section need not.be completed'if the permit valuation Is for $100.00 or less).
(y) I certify that'in the performance of -the work for which this permit is issued,
I shall not employ any person 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
C/de I Sh II forthwith comply with those provisions. -
,pate: �l/a��g— Applicant , O ' r
`T'`".
Warning: Failure to secure Workers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition 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.
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 certifythat 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' i�o u� 'Date 212 •.1`
-BUILDING. PERMIT ,. PERMIT#r 66
DATE ��'� VALUATION ` `} r TRACT '
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JOB SITE
ADDRESS , `f-'B�J.:O �'+�`Sd�3.i�k'�lr WE� A d 6��1t<r
APN
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OWNER
CONTRACTOR / DESIGNER / ENGINEER } ,R
;: rw,I r'A T .D:..�Tr
r:r IVAIDEi%vs t 'v-�lq r �a� CP.N,1%1AS1
490.41 ivfaaTPOSA
5035 GIFFO D ANT.
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x't1t,�l11aL'S ::i °C C1! 92260
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SPECIAL. fNSPECT.10N ' 9.01-000-423-000 S10010
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LESS PRIE=ri%t.)FEES
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TOTM, itPIE IKi.3' 37-"++ 4 DUE NOW
f.
RECEIPT
DATE
BY
D F A E
INSPECTOR
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL A PROV S
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring.
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)