RPL (9909-201)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
719113 B U2n9no(
Z. 1 . �' � f
/ate 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 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
P
,ance of the work for which this permit is issued.
Ihave and will maintain workers' compensation insurance, as required by
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.
G(3Le:)EN )ir%GM IN,'. -.NW( 117:.tt3 x•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
workersjcompensation laws of California, and agree that if I should become
subj.9of to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. ,! f �f�
,,Date: : . _'' 2 Applicant mss `! �i i. ' ••' �i
Warning: Failure to secure Workers' Compehsatioh cA r g f unl�wf�n�
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 pursbant 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
consyliction, and hereby authorize representatives of this City to enter upon
the>3bove-mentioned property foF inspection pur oses.
`Signature (Owner/Agent) Pate �f 10061.C_
BUILDING PERMIT PERMIT#LZ+►
DATE VALUATION 9i7,►4'1,t47t"►,11(! LOT I TRACT
k.
11 -/, j
JOB SITEt.%-800 1/1 MUIRF.i£!,D VILLAGE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
} RIi;1 LY I.IONMES. Mc.1(l1sL1.Y
1it341t INC.
23 CCiR.i'(�1tATE �,LALA, #245
23 CO3MRATE PLA" In45
NEW1•'f)10'flFAC''f! CA 92660
NEW1?(:tRTMACH CA 92604)
(94�Y)714-4975 ("BL,# 5337
USE OF PERMIT
KKX ANDIC NPA
'WATER FIs ilgtii d.: IW L.F. t iJii.11iV WAU - (4' M t AINi'1vC'r -1. 76''
GAMI)L:N), 01`1 `S'PANIIAHU.
1.3
MINI ATrI) CJ.'S.T 017 CYh'\'.'y''IT1,1(11ON
21.000,ff.')
PE"I", FEE SrrNIMAR
PLAN 49ifiCK E'Isl If3!-L�tK1 •113o?::3y)€i $163.90
l'rlwNrtr�if"i')l�?Jt=��f� f��){1(ii{-'11R-f_E(N) 'J�t4?1Fi
NI X('I1ANICAL FIM POOL ,t11 000 -421 -MID S24.t7�
E-LEM'RI AI. iTL -- FNA)L 10 i -WO-420-0OU $45.W
t •
,n
c; Rk-11 rTAI, CONS-TIZtiM 100 ANO MAN CHTCK
$5380)
USS PARE•1'AW FEE S,
$0.00
TOTAL PERMIT FEKS DiJF NOW
$538.80
i
RECEIPT
DATE
BY
DATE FINALED
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
steel
POOLS - SPAS
_ -
Set Backs
Electric Bond
Q
Footings / _ �_
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Pibg. Test
Gas Piping j
v
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:..