9811-058 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (&e Qmencing with Section 7000) of Division 3 of the Business and
Profesai6nals Code, and my License is in full force and effect.
License 41 Lic. Class Exp: Date
Dat` e' `-- ' 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:
( ) (.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
4-8ection 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.
STATE IFUN17
(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 if I should become
subject to the workers' compensation p *ovisions of Section 3700 of the Labor
Code, I shtalllforthwith comply with those provisions.
Date: {4F Applicant_`
t /
Warning: Failure to secure Workers' Compensation coverage is rinlawful.and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on. his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and formhose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work'is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correc5e'lIagree to comply with all City, and State laws relating to the building
c- slruction, and hereby authorize rep ese6 atives of this City to enter upon
C.tie above-mentioned property for inspection purposes.
Signature (Owner/Agent) is^",'r"`' ( `s ��^"'� Date i[ p
s
BUILDING PERMIT PERMIT9811-sl
DATE VALUATION�.5f� 4� LOT TRACT
JOB SITE
ADDRESS 79-124 LIGA w.
OWNER
CONTRACTOR/DESIGNER /ENGINEER
'fl',OYHain.�.: x1..•7l>�'1' Y.;r1"t l�A1J"�
IIiJ A4 vo.d.$,3,%_
CAL" (00 iijA y(.01"' A
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PtaK VLAzii S E'1041
74-7251014.1. OMV.13, 5t1
MVIN .'. CA. 92614
PALM 0ESL,.W1' CA 92260
(7ffl1:34+14010 {",Klff 355
USE OF PERMIT
0
1°ui IL AJND/oi,. SPA
"PvCri.il�c�l7NTfl1N �r t3)1� ,:�11.t1ix14i�,tUtitf'i"€SFtIT,L. Ztfi r17`' �} ';
.`
NOV 09 Im
PL.R,JL MNf.MR SA to 16,500.00 LS
3'
t
:- :-STMATED C- f O1+ WN ISa Y UC k'Ttr N
3.Ci 5110 oo
PEWIT F r1it, INiRWIVILARV
PLAN Ci ffiC FEE 1.01-OUO- 439-'318 $1.17.00
CONITIR1'MMMONETE M-000-418-000 98400
tNIMIANT ICAL + •`-3 «-.POOH 901.000421-000 $24.00
E,,►at:IRI AL M, -- POOL 401-000-420.0003 S45.030
PLUMBING G POOL 101.0-19-OOQ
SAM -TOTAL CONSTRUCTION AND PLANc;F>th
oo
L Is S PREpt��tr r y K
110P0.00
TOTM, PEJRM rf FEES DFJE:INC'M
$393.00
RECEIPTD
T
7'
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
jrms�& 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
AK
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
— .>
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test2
-1 2 -0 -
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)