9912-022 (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
65612£ C53 f 2
Date 16 �� S Signature of Contract ! r'
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. aye:
Carver �r y �^t Policy No.
. a.i'k1d'L+,IFU31,01 (tvr-.gR.( fE�'�u`u'-311.
(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
workers' compensation laws of California, and agree that)fd%should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those pRwvisions.;�_`,---
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 aws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspectao.R purposes.
Signature (Owner/Agit) �Z Date 1Ir et.
CDAT BUILDING PERMITPERMI
VALUATION t�1' 9d:� }i�ti.11� LOT TRACT
oc
JOB SITE i -*449 (.�x'�UNO
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
44AP.�aiA� P�� Odp
0AT IfIr »`t*:{xi u�}'u�r ♦tisfriizl
/ -0810 CA1,.t..t;k b'I i�I rL� tJr tDI
4- 125;�`- N1 DRIVE, #A
LA. QWN t o -C.A N253
.a A LM DES•N.I r CA, 92260
.jf0) 44t)-�atiilU CoLft 151q
USE OF PERMIT
kit 3i }1„ ANDA'-sk S*1A
P013.1, / .Sett,.0ML -AUoRk5h'.19ARI'E IFR -a' :dJ'L191..i. BE IN PLACE Alt 4•'RE
}CXX. aiiv'9` IOR VA 1.6.80f ,00 LS
01.. f iAA LIolff.'D CIA., il.. OF COiR+aSTRUCTIONN
1 gage)
PERM—if R", lWAMARBA
;
C-Ct-�'.2� 1 ! > ?•r- 0.�t, Q1., M-000-421-000vf,t)11
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s
-
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Sri,-'4UTA{, c ONSI RI 3C'�!°tUN AM PLAN CJWC ►.
$393,N)
LESS. PRE -PAID FEES
20,00
RECEIPT
DATE r tT.
BY
D FINALED
INS P 0
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
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
Drvwall - Int. Lath
Final I I POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Hacks Electric Bond
Footings Main Drain
Bond Beam Approval to Corer
Equipment Location
Underaround Electric
al
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
Final
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underqround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Tema. Use of Power
Utility Notice