9704-117 (RPL)LICENSED CONTRACTOR DECLARATION
U) 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
I—
N W Professionals Code, and my License is in full force and eff ct.
C') : License # Lic. Class r exp. Date
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Z /Datet
'� Signature of Contractor �s ���� j
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J U °� OWNER -BUILDER DECLARATION
W W (0 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ d License Law for the following reason:
Z_ ( ) 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).
M () I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
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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
Sdction 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 become subject to the
workers' compensation laws of Californialand agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those,provisions.
Date: Applicant—
Warning:
pplicant !1 '
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 afVCity, and State laws relating to the building
construction, and hereby authorizeyrepresentatives -of this City to enter upon
the above-mentioned property purposes.
V/SigCature (Owner/Agent) ✓ Date—
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BUILDING PERMIT PERM T# �°NTRDL#
9704-117 5043
DATE VALUATIONa'�r.{4th LOT TRACT
JOB SITE. APN
ADDRESS- 791-79_5, [AGA 769-S60-049
OWNER CONTRACTOR/DESIGNER/ENGINEER
Si1Ari1�#t�ra (.A__fA 0R'NtA 0001,,�S, & SPAS
74795 LIGA ti 17.5 J0N1 DRIVE, AA
L8 QUINT A CA 92253 PAL N4 DESERT CA 92260
(76(f)340_0000' 81A 4.
USE OF PERMIT
POOL
XAA ON, r`
PQ3. AND,'61R .Sst:/A
-1,000 00 L.`4
104 _000 419_311 $4.0,75
KIL01KNtCAL t"l?!.'s -- P.00L 1-000 S�1.fafi
I 0 000-420-000 �5.s313
•: It�t,f ff f l :� -�r�c� .r�� 101-000 4191.00O s o
stir3A iriwm, C"aroavjc- o} mn P) AN CHECK. ""� "•F M
LESS t?!'ZF.-3'x,:1131 ESTOTAL NPRAUTYCE14 OUR
: XUO.019
RECEIPT DATE BY DATE FINALED INSPECTOR
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RECEIPT DATE BY DATE FINALED INSPECTOR
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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
OX 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
c
Underground Plbg. Test j
Final
Gas Piping
PLUMBING APPROVALS
Gas Testlet A=
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final -
COMMENTS: a�
G �%%i���
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Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)