0108-121 (SOTB)U)
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LICENSED CONTRACTOR DECLARATION
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 # Lic. Class Exp Date
Date Signature of Contractor
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 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 & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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
Code, I shall forthwith comply with those provisions:
Date: T_ Applicant
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 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) -r—T Date 7- -4
BUILDING PERMIT PERMIT#
DATE VALUATION LOT .i]. _;4�'1 J TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
A9-499 ROWER DR
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USE OF PERMIT
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1f1A.11H OFPI
RECEIPT DATE
BY DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
F DATE
INSPECTOR
OPERATION DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _
Forms & Footings
Slab Grade
Steel
_
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
_
Roof Deck
O.K. to Wrap
F.A.0
Compressor
Framing
Insulation
Vents
Fireplace P.L.
Grills
Fans 8 Controls
J
Fireplace T.O. _ _
Party Wall Insulation
_ J
Condensate Lines
Party Wall Firewall
Exterior Lath _
Drywall -Int. Lath
f
- - - -
Final
BLOCKWALL APPROVALS _
_Set Backs
Footings
Bond Beam
_
Final i
PLUMBING APPROVALS
_
Waste Lines i T j _
Wales i'gp1ng I _
nlurnhing Top Out j
Shower Pans j
Sewer Lateral _ _
Sewer Connection
Gas Piping
Gas Test _
Appliances
{
Final
POOLS -SPAS
Steel -
i Electric Bond
f Main Drain
_Approval to Cover _
Equipment Location
Underground Electric
_
I Underground Plbg. Test
Gas Piping
Gas Test _
Final
_Electric _
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster_
^Pool Cover
Encapsulation
_
J
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)
9096944113
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BUILD
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T-943 P.002/002 F-579
)F LA QUINTA
SAFETY DEPARTMENT
777-7012
ION REQUEST LINE
777-7152
HOTEL IASL
Pgmlt Number 0107-107
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRE$$ 49-499 EISENHOWER DR
SUPPLEMENTAL TO PERMTI' 0105-121 TO
REFLECT ELECTRICAL FEES
TYPE OF INSPECTION DATE INSP.
FOUNDATION & SETBACK
ffT17UCTZ0111:I owj&i i #,`
GROUND PLUMBING
PRE -G UNITE _
OO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNEI
CONCRETE SLAB
JOISTS & GIFIDERS
ELECTRICAL GROUND WORK
1-2
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS 13 N GNE[
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
HEATING & VENT- AIC
FIREPLACE
ROOF
BOND BEAM
O.K. TO WRAP
GROUT ❑ 4' ❑ 8'
FRAMING c
INSULATION
PRE -ROOF
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
DRYWALL, INTERIOR
EXTERIOR LATH
POOP, PRE PLASTER
POOL FENCE & GATE
SEWER SEPTIC TANK
FINALS
ELECTRICAL
PLUFASING
FINAL GAS TEST
HEATING - AIC
HOUSE NUMBERS
JOB COMPLETED
TEMP POWER
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING