0012-143 (RPL)LICENSED CONTRACTOR DECLARATION . - ►J
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. .
Licensef# Lic. Class Exp. Date
/:3>�5 C53
te_: Signature of Contractor -"Z -,,,, I,,—' -----
i
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 isnot 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.
1 have and will maintain workers' compensation insurance, as required by
S461ion 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.
STATE FOWD
(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
wor!3rg' compensation laws of California, and agree that if I should become
sub'ect to the workers' compensation provisions of Section '3700 -of the Labor
C7e, I shall forthwith comply withAhose provisions.
`date: I 'N • 12' Applicant R -_ . h•�- �.:—....r
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 & eacii.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
const ction, and hereby authorize representatives of this City to enter upon
Ythebove-mentioned property forinspection purposes.
ature (Owner/Agent) "-" �� r--- - Date / Z• '`'• t'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0012-443 TRACT
283401-z
JOB SITE
ADDRESS ar� aa�+ff��yy q�/9p� eypq
OWNER
CONTRACTOR/DESIGNER/ENGINEER
WM TMLMAN
Cl1�..'�'iRWATOOM AWNS
80-329 Ri.V.JY'RA
74•1.25 a%4"LYS,M MVE, #A
x..AQU:iMA Cie. 92253
PA D SHUT CA A-260
.(760)340-9000 (MVf. 5386
USE OF PERMIT
PCY:LAMOP,VA,
ONL-A[Ab2.MSO43•ARRIERS SHALL HE IN PLACK A r PRE. PWITft
lleiSPECTION.P001, EQU1PMEWNT ENCLOSURE 13 NOT I14C:Lt11:►M)114 THIS.
POOL AND/OR 5141ri L»4
• a
Evil I�+!IrD 4p�3�"d` - F C'i)1�N:STt@l+>v.�YOW
16; ,
PARM3 01K9 8MMANY
PLAN CIDIC K, FEE 1 SiI .,000.A, J9.%18
CCik1;3TRUC TIOW FEZ 101-. 00.4113-000 $1$0.00
MECHANICAL "M -- POOL, 1011=000-121-000
E1.4LCTR'ICAL:N'1%— PWL SCI) -000-4202 000
F&1+aTm3 o viv. -- .POOL., 1 oT .00p-41 w000 fG a 7, fdq
r
I�3UB-'£'iJ AT., 01014 .°t�UC 1110N A1.19D ALM. CRECK
USS :PlT'ePJVD M."J
$0.00
.AOId7.1•.G 11700V _11.'.!i!YY
$393AX) .
RECEIPT
DATE "
By/O {
DATE FINALED
INSPECTOR
11 C
j (/
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
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
Exterior Lath
Drywall - Int. Lath
s
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
p/ G
Gas Piping
Gas Test
Appliances
Final
if d L
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)