RPL (9912-038)LICENSED,CONTRACTOR DECLARATION
.J 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. I; ..�,
License # Lic. Class Exp: Date"
ate f'�if.) 'Signature of.Contractor
OWNER=BUILDER DECLARATION , a
I hereby affirm under. penalty of perjury that I am exempt from.fhe 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)-.
( ) l,.as owner of the .property, am exclusively contracting with 'licensed
contractors to construct the project (Sec. 7044, Business' A. Professionals
Code). _
() I am eicempf under SectionB&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, a's provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit'is issued..
(NY 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, & poliy.no` are:
Cartier PolicyNo..`
- o i i?'� �-t;�i�Ll . Y3-itj•,t v ill�tT�+'.ua3 ',:? .
(This section need not be completed if the. permit valuation is for $1'00.00 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 Callforniar.and agree •tfiat ifdl should become
subject to the workers' compensation` provisions of.Section 37.00 of the C bor
Cade, I shall fortkwith comply witfi`those provlslons
(Date: !') ?.1 r1 Applicant'fg • t} 1= L
Warning: Failure to secure Workers' Compensatioltcor gveis .unlawful,and` ,
shall sub1ect 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 thisapplication is'made & each person at
Whose request,and for whose benefit work is performed Linde r.or, pu irsua-rit 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 permif to can
I certify that 1 -have read thiS' application and state that the above information is
correct. Iagreee to comply with all City, and State laws relating to the•building
constytlon, and hereby' authorize representatives of .this City.tozenter upon
Zure
ove;mentioned property for inspection purposes. i
(Owner/Agent) It �t �� � �l •' Date ���'��l r
t
PERMIT #
-BUILDING, PERMIT
DATE ) VALUATION S uyn"i'•{3� j (� LOT TRACT
JOB SITE
40,42.0 NIUSION1 1 DR''xrVE VVIS'V
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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LA. ea l i ( -,!A 92"1'5�
PALM i%>L,S�,.4:'r. Q4 to,2269
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USE OF PERMIT
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TA,'AL 1`.C.34.fi69JT ri",CF-3 DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
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
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
wnd Beam
Approval to Cover
Equipment Location
Underground Electric
/— . CIC5�
Underground Plbg. Test
Final
Gas Piping
C•1
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
dif
Gas Piping
Gas Test
Appliances
Final
v �j
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: