9912-019 (RPL)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
ONA28 C53 1Q,39w
Date12 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
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 , n ,,, Policy No. RIOr 1,
-if A
(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 sub ect to the
workers' compensation laws of California, and agree that 4A should become
subject to the workers' compensation provisions of,�Qction 3,700 -of the Labor
Code, I shall forthwith comply with th'Si s~ -
Date: Applicant
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 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,rjaiiiig to the building
construction, and hereby authorize representatives, 6f=this City to enter upon
the above-mentioned property for inspection*purposes.
Signature (Owner/Agent) ` /��"� Date �?
BUILDING PERMIT PERMIT 991 Z-0 V)
DATE % VALUATION 118,M.00 LOT TRACT
JOB SITE 79:1'
APN
ADDRESS ,LTKINO
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MAR :'IN HUMPS
V.1,1AFORINTA s".X3IS S. SPAS
79-080 CAUIF ESMDU SIT: 201
74-725 KiNI DRIVE., i3A
LA QUibiTA CA 02253
PALS DESFIVI' CA 922W
t?t,ED1:� 09000 CELO 355
USE OF PERMIT
KOJI, A141)AJK ,%J1A
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VtDOL ANDACIZ SIVA IR,3(iiJ.(1f) I'S
F,g,rij QST iii t"(3,'�:''3o1 rt'tli�i
131.11.110.09
PE.RMIT FEE SlJi1 MARV
Pl r'HECK h�B 1014XW-4 ui-318 $12870
-AN
f"t+N4"m,Iif"I'iO U f:Fr 1111 -{U')0 -AIA -i10() 5141110
NMIXIIIANICAL M', •- POOL 101 OW -.1211 0W $24 n
YJA;4�71 R i C AL FM -- W-401, 101-001) 4MOW S0 (0)
Nt.lRWONO HI li -- I'r'rt.)L ) 01.011)0-419-(W $27 (w
Si t(�: tt t'1'14I, ("(:)►JS"I1211( `1'101+1 ANI7 P(.AN t'I)FC'K.
%421 70
LESS PRE TAID FUS
SO 00
f0fAfi, PERMIT Zr'I' M 011I1X NOW
$422.71)
RECEIPT
DATE
I /
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
POOLS - SPAS
- BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test dT
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fudures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)