BLDG (0012-193)LICENSED CONTRACTOR DECLARATION.
I hereby affirm under penalty of perjury that l am licensed under provisions of
Chapter 9 (commencing with Section -7000) of Division93 of the Businessland
Professionals Code, and my License is in full force and effQ.17
License # Lic Cla 's Exp. Date
Signature of Contractor ' t•,��}`'/��
OWNER-BUILDEWDECL'ARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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.exclusivelycontracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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.t
(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 issue_d:'My vkkers'.compensation insurance carrier& policy no. are:
Carrier 7� p Policy No.
(This section need not be completed- f the permit valuation is for $10 00 or less).
(,) l certify that in the- performante a of the work orjwhich this permit is issued,
I shall not employ any person in a manner ,so as to become subject to the
workers' compensation laws oflCall ernia;-and agree that` -..if I should become
subject'to the workers' compenkationpro�visions of Sectl6n.3700 of the Labor
Code, I shall forthwi�F� comply wit}�t those•p rovistons.;
Date: ) l ,1 f • . Applicant"% { dr'`
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 compensatiori damages as'provided for in Section 370. 6
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 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 o �`RNuance of such
permit, or cessation of work, for 1.80 -days will subject Pmitito cancellation.
I certify that I haveread this a plication and stage that t�,h'e aboljve information is
correct. I agree to Amply with a)t City, and $ tate! laws relating to the building
Construction,-and.hereby auori a representatives of thisoCity to enter upon
the above-mentione i,p opertVi for inspection purposes '
Signature (O.wner/Agent) " Date
BUILDING PERMIT PERMIT".
DATE VALUATION LOTTRACT
JOB SITE
ADDRESS
APN
"79-" S 1�!d�".d::CON
OWNER
CONTRACTOR / DESIGNER /ENGINEER
ROOT FEURY
A� � 3t CFzr3k c�
0.,wi Y'�;:. 471 ROJ s
. Q'`. NTA CA 92253
PAL,M I:rOMMT CA
92261
USE OF PERMIT
111.93 b 2016w 1�ATTJJ Z ><'A110 COIN ,"R, :.
f oko'WF`.A°1 O 293.00 8F
ATM). COST �6. F �a4fM�WaM1 CIrI�l.C� � .
- -yy�
� 3,M,90
.,90
�yy yy��>> ���^^��qq',,pp �.dj'+�~A8e.V
PI.SSAd.1.I'MVE S9L�iS7.#�iW8ARY
.
pum amer, ?SER
C:tNSTP,WPIO FEE', 2 01-00-41 8-W.0 00
i OQ�f� l C+`iY ii FKK _ !•iV; ID, 101.1000-20 I -00
TOTAL 11TUVM�11',1=5 ME NOW
RECEIPT
DATE
BY
DATE FINALE
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
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 /
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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: