RPL (9710 018)L°NSED CONTRACTOR DECLARATION
I hereby aff.iin unt :, 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 ane( effect.
License # Lic. Class J Exp. Date
C:+Yij eS i ,:
I W3 108
J"
�� 7
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, as owner of the property, or my employees with wages as their sole
compensation, will do the work, andthe 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 Sianature 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.
,K 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!! 7r�. Policy No.
AM•ee
Y yIVIS } {jD iT�,J,f ". Id •i l
(This section need not be completed if the
() I certify that in the performance of tl
I shall not employ any person in any mi
,workers' compensation laws of CalifomA
'subject to the workers' compensation' pr
Code, t, shall forthwith comply with those
Date: Applicant ,./`
rmit valuation is for $100.00 or less).
work for which this permit is issued,
ler so as to become subject to the
and agree that if I should become
sions of Section 3700 of the Labor
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 & 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 18,,0 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 appli(
correct. I agree to comply with all
construction, and hereby authoriz
tfie above-mentioned property for,
Sighatu e' (Owner/Agent)
and state that the above information is
and/State laws relating to the building
'esentatives of this City to enter upon,,,
tion purposes.
01
Date
PERMIT # CONTROL #
BUILDING PERMIT- ���I' ��r� �-� 6033
DATE S �i.l VALUATION LOT LOT TRACT
JOB SITE
ADDRESS 'ISU-3491F�XI;.3tli./t�
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
6440 :KIA :k-LhO
74-723 JuNI a KIVI-3. fay
CA W215,3
PAIM VANVXT ("A
USE OF PERMIT
i JOL, SP,A tu. S4()
4 y'',�",'.i"{•�y' i'i'a1� '1�`y�.!':^ e^tYi /q 1�'t'�y R ty'r. g'ip��S
9 F (� eLa;
PLAN CHECK F11E, 8tµ) 4S
1ni -0(0t 4.41.(i?-dKil1 Rt531XI
FM — P(: tk 1c0110. OGO :;l).-000
VEE �A?Ak!
AW) 1ef M4N f F1} f„"iY
t1 S4
bGT 101991
TOTAL NOWNTIT FEES @, VE NOW
$349.4
01
RECEIPT
DATE
BI
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
INSPECTOR
OPERATION
I DATE
I 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 q
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
Final _ r `
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
�Exterior Receptacles
IMF. 1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: