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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
rofessionals Code, and my License is in full force and effect.
License # Lic. Class_�-% Exp�-,Date
690045
���9§ionature of Contractor'A - — -------
Date
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( -) 11 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).
1, as owner of the property, am exclusively contracting with licensed
bontractors to construct the project (Sec. 7044, Business & Professionals
Coae).
I am exempt under Section B&P.C. for this reason
Dat6 Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I ha�e and will maintairi a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
pelrformah'ce of the work for which this permit is issued.
hav6 and will maintain workers' compensation insurance, as required by
,,Sbc ion MO of the Labor Code, for the performance of the work for which this
pOrmit'is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
0 -
(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
w6rk6rs'..compensation laws of California, -and agree ' that if'l'should become
subject to the workers' compensation provisions, A 'Section 3700 of the Labor
Code, I -shall forthwith comply with those provisions, I
/Date: 41. rf Applicant
Warding: ' Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employerto 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 bermit issued asa result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
i 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 bf work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
cqrrect. I agree to comply with all'Cifq, and State laws relating to the building
cohstruction, and hereby, a-u-thoriz?,rbpresehiatives of this City to enter upon
the above-mentioned �roperty for/inspection purposes.
Signatyre (Owner/Agen
PERMIT#
BUILDING PERMIT
94)
DATE VALUATION 5,11101.011.00 LOT 17 TRACT
,� - 1("/. -/9
JOB SITE - I
ADDRESS 781-8-10 CA&I'LE KNES ORM,
APN
OWNER
CONTRACTOR / DESIGNER ENGINEER
ii yr rAp
0'.14 ,4 (vc, t
PO WJ11% & 10
i, d 2 5 E', t PM W R 9 f F Y D RV% 1E
LA 001PIMA C*A 9-M�3
PRUENIX AZ 100341
(607y:57 -165A ilq%
USE OF PERMIT
PCOL -ANEWOR 'SN'k
,POOUSPA,
POOL IVA
-11) COST CON114411 11111ICTION,
1,4101VIATE
11 114010A)v
iTIRNiff PER, WINIMARY
PLAN40MCK FE13
C0Wrrr%AfCTXYN FEE 101 _01,10-419-000 M
Nir
, XMANICAL F CC., - - PCX)L 1014900-4221-000 VVIA
ELESMUCAL RM, - P00L Y001 -W-11420-000 S4 -j, 00
PLtfMR)N(J FEE - P001, 101-000-419-000
SUA�TOTA_1, rNONISTRUCTIONAND MAN Cf IRCK
.4 0
LESS PRE-PAUDOEX-S
$0.00
TOTN't, PERMIATP'ERS OVENOW
$10113,90
R ECEIPT
DATE
I
BY
I
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
Patty Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
I
Final
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
C? 1,ell(
Set Backs
Electric Bond
Footings
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
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
Temo. Use of Power
Final
Utility Notice (Perm)
COMMENTS: