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LICENSED CONTRACTOR DECLARATION
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by affirm under penalty of perjury that I am licensed under provisions of
er 9 (commencing with Section 7000) of Division 3 of the Business and
sionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date _,,,:'�
fe Signature of Contractor
OWN ER -B UI LDER`•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
perfor ance of the work for which this permit is issued.
r' Inhave 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 Policy No.
(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 becgme subject to the
workers' compensation laws of California, and agree�•Sha' if I should become
subject to the workers' compensation provssions of�Section 00 of the Labor
Cod I shall forthwith comply with those gv6Gis�
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, indemnity
& 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 thVthe"above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize rS esefitatiives of this City to enter upon
the above-mentioned property purposes.
�f6ture (Owne`rlAgern^t') - Date Z�
BUILDING PERMITPERMIT #
TE VALUATION 17 TRACT
ADDRESS 7'9-402 °� �.lft'l�'..4N0 JOB SITE
APN
OWNER
CONTRACTOR / DESIGNER /ENGINEER
MM"lI ZINC
CAIL-'IF RNIA'f LOS & SPAS
78-Q30 CALM.' FS-ULD0 STE 201 -
74.723.iOW DRIVE, fill.
LAW1M-A (-:A 9225-1
PALM i1ESt.iiT" CA 9220)
(7fiDl�4t}-+3�Gtf) f'1=T,y ,i5i
USE OF PERMIT
31CA)II A� SPI�t ONLY - A,LARMIYOARR.iE.W. SIIALL ULI !N f'E.AC'E AT PRE
PLAS SER 1NSPIAC1'10N.
POOL t110011OR Sir's 14,31WOO Ul'
PLAN C'H4UC71 1+1t' t0l -fW-X5314-318 5105.31-1
f"N'S-M I ICMON r14-. t (1 T -f i(?l7-d I R- ()fl S 1 roll 00
c��Ifr��.tslch). FIM. --11001. .01 000 -421 -OM S2 M)
f1t.Ei.''it2i�'Af. [ h.[: •- N+_n +L ioi-000-42G" :�i5.+ ►
}'I.tlfviBINOFhE--fCX-))_ 10; -OW-419-M) S7.7M)
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S363JO
3
RECEIPT
DATE
By---
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I 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
0. 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
- g, -i-
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Col. IF
Underground Plbg. Test
Final
Gas PiRing
— �Z Ci
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.IC for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
LIZA.-
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: