0110-126 (TT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury am licensed under;provisions of
n Ch4ter 9 (commencing with Section 7000) of Division 3 of the, Business and
Professionals Code, and my License is in full force and effect.
License # - - . q Lic: Class - y, 1µ Exp. Date .y
Date AL,�/�''r - Signature of Contractor ,'r, �'f>�_'
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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'fbr
sale (Sec. 7044, Business & Professionals Code).
( ) l,- as rowner 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 oneof 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
Se tion 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:
Cam erTATC Policy No.�� Q°91ri
(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 ofTSectio ' 3700, ofrth'e Labor
Code, I shall forthwith comply with those=prgvis&onsf ,/
c r� . ..,y Applicant:a�;�'�
Date:, -,',7
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Warning. Failure�to secure Worlie�s' Comp satiori coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1100,000, in
addition to the cost of compensation, damages as provided for in Seen 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 ohA..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�irnspection purposes
Si nature (Owner/Agent) / 111Date
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BUILDING PERMIT PERMIT#0110426
DATE VALUATION LOT TRACT
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USE OF PERMIT
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INSPECTION RECORD.
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs i F
Underground Ducts
Forms & Footings
Ducts
Slab Grade -
Return Air
.Steel+ 't
Combustion Air
Roof Deck y
Exhaust Fans f
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 Y
Exterior Lath s
Drywall - Int. Lath
. "
Final
Final
BLOCKWALL APPROVALS'
_ POOLS - SPAS .
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Y:
Underground Electric
'Underground Plbg. Test
Final W '
Gas Piping
PLUMBING' APPROVALS':.
Gas Test
Electric Final
Waste Lines 'b'• * , ,
Heater Final
Water Piping S
Plumbing Final
Plumbing Top Out. -
Equipment Enclosure
Shower Pans 7
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 7`-,
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)
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