RPL (0101-358)51800 Avenida Madero
0101-358
LICENSED CONTRACTOR DECLARATION
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.
License # Lic. Class Exp. Date
j
Date !Z, rf 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, 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 COMPENSi.TION 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 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.
11,D. ,,lr71Y,ACR )WC 322504-06
(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 370019f the L bor
Code, I shall forthwith comply with thoseprovisions1. g'
Date: t Applicant ,V
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 fol n Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to th^ Director of Building and Saf
for a permit subject to the conditions and restrictions set forth on his
application. r
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 inspection ppufposes
Signature (Owner/Agent) rDate
BUILDING PERMIT PERMIT#
DATE VALUATION LOT dY,h11—a1 TRACT
$71%Q.00
JOB SITE
APN
ADDRESS 31
BttyyO pp MMe
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MMK b't7b"EU
SUOROEM COklPORM.769
76_9Z 1WRIDAINE WTI.;
'12.850 SOMMIL% ROAD
aaJ11A Duhrle t r Cr`*, 92260
: AUM D1+ RT CA 9P260
(760Y345-7186 CSLif 1137
USE OF PERMIT
PR"dOL"Dlrbl`R f+,;,A
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NOR i"IASUR AISPECTIOR POOL, EQUIPMKHT ENCUMU 10 NOT
h 1C .UT)1!15 TP2'➢`t lu't irldl l '.
1'0 1.9,1 5°1fO w t Z50010 LS
IS x'(IMA ED COST 00 CrO.PUST1MC ION
PLAN CIBECK FE It 101-000-43.9-110 S64,35
07014S2'R UC T1014 VELF 101 _000-118- 0100 599.01)
ETA1,'{ TRJCAL FEE— , OOL 101.000.4,77.0.000 $45100
P11URABINO "IF — POOL L 101-000.419-000 WAD
AL.
SUB -"'AL C .0MMUCM1014 f!:► D .FLAN' IC:`9'I:ET.CY.0
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RECEIPT
DATE r
BY4
DATE FINALED
INSPECTOR
I F"• 1
/Z .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
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
Final
Final. .
POOLS - SPAS
' BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
_
Footings
Main Drain
$
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
V
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APS
FOR CONSTR'U'CTl%'— N
DATE I