9710-025 (RPL)_ LICENSED CONTRACTOR DECLARATION
,I h6rAJIMitirm under penalty of perjury that I am licensed under provisio'
t-Chai—erw 'mmencing 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
98
Date. i= S�Signature of Contractor ��/'
`✓ V
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.
.h) 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.
�.S 1. el.A .f.l .Fl.if'FID 06 775 ; `3 i r -y6
(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
Jode, I shall forthwith comply with those provisj. ns.
Date:fir._' I_ 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 this
application. .t
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 Js
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
t e above-mentioned property fo nspection purposes.
/ / ,t
Signature (Owner/Agent) -' / / { Date
PERMIT# CONTROL#
BUILDING PERMIT
DATE VALUATION LOT LOT TRACT ;±
JOB SITE.R-✓` :3 OAK RILL
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
i' �.A.NC[.4i.;i i.VAP t' STii,fi C)
CA, 1, 9..F(7)RIN1A dredi,S & 8Y.AS
79-6877 C 1JUMMY L LUB
'14-7/25 JON1 1 i. U E, YF A
WDO CIS
PALM Ca:1 SERI CA W2260
USE OF PERMIT
POOL
PCR,�
4t:As1YA,Q MA-171)CY11.3S Oi•i.,+✓ T.s RSC.i/'A. Y. x�.:Yli
].V -row f
1,"ERMIT FEE SijJMMAAd V
coNvTl lYt^C't(1Af j:6 ? {U1,—fZdli t -f1( $15300
�. t 1 r � � �• P Y\ 1 .aria ti. r
&EICs .auk 1�: at.iTEE-• rl r, /L r -t<a �ir�.t,J
C1X11(11Wf Ali. ► h . I'A0 1 llD:i�fi(it -d:�tA.{iUC1 Yi4�.r
I•'Lt.3tN131.t�f� f .�'1".��. -- t� pE;el, i C) i-(1q�-191 �?-Oi?0 �'2 f,�tf
't
Sl `,B.'t'r-)" A is i. T)NSMR,,l K -110N AND PLAN (1-11"C K
$'3WO
8ej f. ESS PRI -41 -1 -PAID FTE -S
4X00
f(TI(Al, PFRNflT NOW
"OAS
yDATE
RECEIPT
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
j INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Aat
Backs
Underground Ducts
I
Farms & Footings
Ducts
I
Slab Grade
Return Air
Steel
Combustion Air
i
Roof Deck
Exhaust Fans
f
OX to Wrap
F.A.U.
f
Framing
Compressor
i
Insulation
Vents
Fireplace P.L.
Grills
[
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
E
Party Wall Firewall
Exterior Lath
I
Drywall - Int. Lath
r
v
Final
I
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steer,44:
A,I
Backs
Electric Bond
_Set
outings
Main Drain
-
Fond Beam
Approval to Cover
E.
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
t
Waste Lines
Heater Final
i
Water Piping
Plumbing Final
I
Plumbing Top Out
Equipment Enclosure
[
Shower Pans
OX for Finish Plaster
t
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
3, ( —?_Y
Gas Piping
Gas Test
Appliances
Final
4 —1(- —T LJ Z
COMMENTS:
'
}
Final
4
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
4
;.'..
Temp. Use of Power
Final
}
Utility Notice (Perm)