9903-226 (RPL)r - LICENSED CONTRACTOR DECLARATION
-1" 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 EAp., • ate
6.56125 '.. C53 10131100
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, Sas 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. r7044, Business & Professionals Code).
(.) I, as •owner of the property, • am exclusively contracting with licensed
contractors; 'to construct the project (Sec::7044, Business & Professionals
I( I:am exempt under Section B&P.C. for this reason
Date Signature of Owner
a 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) 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
per is`issued: My workers' compensation insurance carrier & policy no. are:
Carrier Policy No..
STATE �i11+Tt) y. U 3��39-0006'168
(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'thflt7if I should become
subject,to the workers' compensation provislo, s-66 S�elction 3700 of the Labo'rN,
11
Code, l shall forthwith comply with those pros i"sions./{
Date: 'r ?j Applicant --^ ,
iiWarning: Failure to secure Workers' Compensation coverage is unlawful and
,Shall -subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. "
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth 'on his
application. '
-` .1. Each person upon whose,be.half this application is made & each person at -
whose, request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
&ahold harmless the City of La Quinta, its officers, agents and employees.
2. Any. permit issued.as a result of this application becomes null and void if
!.,work is not commenced within 180 days- from date of issuance of such
permit,:or cessation of work for 180 days will subject permit to cancellation:
I certify that I have read this application and state that the above information is
correct. l agree to comply with all City, and State laws relating to the building
r
construction, -and hereby authorize represQntatiy� of this City to enter upon
the above-mentioned property for inspection u poses.
Sig aturei(Owner/Agent) Date ;Ai I
BUILDING PERMIT,. PERMITp " .
DATE VALUATION LOT 9901 ' Z6r TRACT
.3124199
JOB SITE
APN
ADDRESS W304 RIVIERA
r
OWNER
CONTRACTOR/DESIGNER/ENGINEER
KIST, 1,ANT.)1..1 CO:1zi ORATION
CAl.1.FORNUS.'1~C7OI S & SRAS
55.92.0 PGA BLVD
74425 JONI DltINT, 74A
LA QUIMM. C:A 9,2253
PALIVI DE?SE .r CA 92260 , r
(7W)340 -9N0 0 31:1# 355
USE OF PERMIT
Pock ANiCt O R SPA
P-304. Slew & 813Q (INCLU315 R OCAi'iNO Or, NC C -CH SMING
tJAti i'';. A.L.AIr':(v1S1t3ARRIE 2 r SIMAL:L M, I PLACE Af, PRE -PLASTER
POOL AND/OR SPA L1%
4. F C,'�$l+ln$iucrit"N
PERMIT FEE SUMMARV
PLAN CHECK FFE 101.-100-4351-318
CON4?f?fY7r10N FEfi .101:-0�0�041►8-((N�3/0�
FEM, l^VSdtY ,H�D.57
* iMCHA11.11CAL l l U ^. P'00L 101-000 4.21 -OM
1,-3..0 .1`1tJ.CAL T'.f . __ ,P00L 101-Utlil-420-0110
AIMBING FMI.F, -- ??OO 10) -OW -419-0(g) �Z7.00
SL"3-'1;C TA3,r CONFINUCTION AND PLAN 1"::ITr,
$4?.4.35
USS PRE=P,A, D FEES
X0.00
�
.
T A L d.gpn.Fy+i o,u Now
• N
RECEIPT %/
1
DATE4 ��'
BYE
DATE FINALED
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
0. 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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
_
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
Al
Final
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)
COMMENTS:
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---- E. G A SAFET PART ENT_
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CONDITIONALLY
ACCEPTED FOR COiySTRUC TION C W
SUBJECT TO INSTALLATION AS PER
AND ALL APPLICABLE CODES 3
BY --If,; .
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