RPL (0211-072)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 andd'
Professionals Code, and my License is in full force and effect. .
License # Lic. Class Exp. Date
Date.* ��'Signature of Contractor
OWNER -BUILDER DECLARATION6'°
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).
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.
( ) 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,'11.€ �g.:t'$j`Nyj Policy 11
No. 10614117-02
(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 3706 of the Labor
Code, I shall forthwith comply wit6hose provisions- :•.
Date: Applicant-
Warning:
pplicant Warning: Failure to secure Workers' Compensation e coverage is unlawful and
shall subject an employer to criminal penalties„and'clvil 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 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 f r inspection purposes` ,
Signature (Owner/Agent)�f '=�`�� Date.,, .11,'W -
.`.,. ING �P�ERMIT PERMIT#
DATE VALUATION . yy�hy �/a6{{yyyy�� ttqqy��� LOT TRACT
JOB SITE f
ADDRESS f•`i..U�el`ite.�.l�.:MW
APN
...
OWNER
CONTRACTOR / DESIGNER /'EN (NEER
T2s, Am, lop1,02. L-AN13F A 3
MACilii MfV-PL1111014Ai,R-:N?' INC
7;5«x'192034MT�' RA10
3.O tox 1685
C.S'1. 922S::•S:
LA Qi)1%!`lA .,CA 42,25,_4
PERMIT
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[[���[. py 00 439. p $134,33
t. ONSi1''tUCTICaW'M 1011 -000 -418 -boo $207.00
.NMCHA MCATI IN i- 000t, 10).-000-421-0 00 1104.E .
1%WF1P.Jf! 01i PRE - ,t'OPI, 101-000-46.f1-0ou $45.00
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e !1207 fgiY•A t�?1
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AAL 1" �EIMM`:�`. V'i 3.3Ux: NOW
�. cay-OF LA QUINTA
FINANCEDEPT
fid,
RECEIPT
DATE �I ,rr r
BY DATE FOALED
INSPECTOR
?'t ;i
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings CQUo
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
3
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
'ewer Lateral
Pool Cover
fewer Connection
Encapsulation
gas Piping
^as 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: