0009-053 (BLCK)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
29172:3 / B HAZ
V to Signature of Contractor_
OWNER -BUILDER DECLARATION
08/131/2C
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.
( 0.-'l 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 STATE FUND Policy No. 220.00 UNIT 0004483
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date ,1 -�� � Applicant
/Warning: Fa lure 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 relating to the building
construction, and hereby authorize,representatives of this City to enter upon
the above-mentioned property foAnspection purposes.
�S gnature (Owner /AgenfDates/f - ..
BUILDING PERMIT . PERMIT /t
DATE VALUATION LOT OW9_053 TRACT
09/12/. * $21166 (KD
JOB SITE
ADDRESS 5is-24. A. �im To
APN
_ a
OWNER
CONTRACTOR/DESIGNER/EN (NEER
STAP 1IO1y^S%/ MAGA viFlrr
WHIJAM RUSSELL ROGI tS
51-�70 Ay1:N'rDABLIWTDAS
56900 W,K ON UT
LA QUIN'TA CA 92253
MERMAL CA 92274
(760)399,1200 CB1* 1954
USE OF PER T
a I'A
100 L11 Y kil.Clt K VVA..iLL • CITY STAF@DAP.D
S IST, WALL 109.00 LF
'&S'M MD COSH OF C.C2.1`1$'M11'LMON
2,163.OD
P' ��kWMII HUMMA]E Y
4;C?MTI2UCTIO'N FEE 1014000.418.000 04.00
Yp zy, t6,
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1PIM- ial-AL C"CT1`1'&MUO:Ti01` AND PLA" C09,.CK
g 54.Ot3
1,?um- PkE.PkD , = ,
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TO'TAi.M R1Vlff>�'1 E'4 D'UE.t NOW
t)�4M
RECEIPT
DATE
BY / /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
'BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs II
Underground Ducts
Forms & Footings] I
Ducts
Slab Grade 11
Return Air
Steel 11
Combustion Air
Roof Deck 11
Exhaust Fans
OX to Wrap I I
F.A.U.
Framing 11
Compressor
Insulation II
Vents
Fireplace P.L. II
Grills
Fireplace T.O. 11
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall I
Exterior Lath I I
Drywall - Int. Lath I I
ii
it
11
Final
Final if
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs 11
Electric Bond
Footings II
Main Drain
Bond Beam it
Approval to Cover
• 11
Equipment Location
II
Underground Electric
)[
Underground Plbg. Test
Final I1
Gas Piping
1.
PLUMBING APPROVALS
,I
Gas Test
Electric Final
Waste Lines CI
Heater Final
Water Piping 11
Plumbing Final
Plumbing Top Out:
Equipment Enclosure
Shower Pans It
O.K. for Finish Plaster
Sewer Lateral if
Pool Cover
Sewer Connection I
Encapsulation
Gas Piping ][
Gas Test i 1
Appliances II
([
Final
1I
l 1
- II
Final it
Utility Notice (Gas)i
ELECTRICAL APPROVALS
Temp. Power Pole l
Underground Conduit
Rough Wiring if
Low Voltage Wiring
Fixtures ]C
Main Service 11
Sub Panels 11
Exterior Receptacles
G.F.I. ' 11
Smoke Detectors li
Temp. Use of Power
16
11
Final II
Utility Notice (Perm)
COMMENTS: