106-194 (RER)LICENSED CONTRACTOR DECLARATION
I heW- affirm under penalty of perjury that I am licensed under provisions of
Imo— Cha( (commencing with Section 7000) of Division 3 of the Business and
cy w Professionals Code, and my License is in full force and effect.
O =)ry co License # Lic. Class Exp. Date
VLJJ
r
Z r-- Date ' ti Signature of Contractor' r• I
J U 00 OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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 & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
r � O () 1 have and will maintain a certificate of :onsent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
coQ () ( ) I have and will maintain workers' compensation insurance, as required by
O C) Q Section 3700 of the Labor Code, for the performance of the work for which this
Zpermit is issued. My workers' compensation assurance carrier & policy no. are:
Carrier Policy No, y ``
CY
J (This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the wo,k 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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I'shall forthwith comply with those provisions. iT!
Date: 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 s 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 PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INEER
1I(TAWEW Kri,is:DENUAL ASS ICIATK*
D.h_ .MNA P?,CIM. (10TE3:iAL C011T."kA M",-.:
PC) BC, :k i n6p
462 's3T{i-MM-1.9 !,41- #302
LA QITDT!.A CA 92253
Sol ANA BFJ4i.'11 CA !rill 7 5
QQ
USE OF PERMIT
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RECEIPT DATE 1 BY
;! r -
DATE FINALED
NSPECTOR
INSPECTION RECORD
OPERATION j
DATE INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Underground Ducts
Set Backs
Forms & Footings
Ducts
—et
Slab Grade
Rum Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.R. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T O. {
Fans & Controls
Party Wall Insulation �
Party Wall Firewall
Exterior Lath I r
Drywall - Int Lat
�7�r - i/%/�/�/ - - -
Final _ E ,id�! _ _ — —
RLOCKWALL
Set Backs _� _ 1
Footings
aond Beam
— - v _
—
i
dal -
Condensate Lines
—
—�
—
Final �^ I
POOLS -SPAS
Steel —
Electric Bond
Main Drain
Approval to Cover � — - •— - — t
Equipment Location
Undergo tuna Electric _
Underground Plbg. Test I �I
Gas Piping
Gas Test
Electric Final _ �—
Heater Final 1
Plumbing Final i
Equipment Enclosure
O K. for Finish Plaster _
Pool Cover
Encapsulation
i
Final
COMMENTS:
p,�
�LI�F� APPROVALS
Waste Lines -I~_
Water Piping
Plumbing Top Out
Shower Pans
I
Sewer Lateral
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
I
Underground Conduit
Rough Wiring
Low VoRage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
v = F.i.
bke Detectors
emp. Use of Power
Final
Utility Notice (Perm)