9710-063 (RPL)s" LICENSED CONTRACTOR DECLARATION.
;.I heref 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
Date Signature of. Contractor% `•,`'""� "
f
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.
1 -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 issuei9: ;My`w'orkers' compensation insurance carrier & policy no. are:
Carrier " Policy No.
STATS F:: ND 1=990- s
(This section need notbe 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 man ei -so as to become subject to the
workers' compensation laws of California, r�d�agree that if I sh uld be`co'e
subject to thO workers' compensatio,�n provilions�of Section 3700 of�the Labor
Code, I stall ortfh Ith comply with.thoseN rovisl�r�s..^
Date: v Applicant �i"''� -
iWarning: Failure o 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 readthis application1 and- state that the above information is
correct. I agree to complNith all City, and State laws relating to the building
construction, and hereby authorize representativ sNof this City o enter upon
the above-mentioned. property, for in pection p R rpt ses.
YSignature (Owner/Agent) Date � 1 I —b—
PERMIT
b
PERMIT# i CONTROL# -
BUILDING PERMIT ifi p�.�V�YL1:
¢¢ �q
VALUATION �.�� LOT Its TRACT i&O'Vt
DATE /II( ^r
gjJJ7/
"
J0 SITE SITE r
ADS ESS ;j}"-445 AVE MDe0.'RAhit' • Z
APN YN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
171; S T.ttEA110NIT
P.0- Box 722
S(N:k.ANSIDE CA ')2054
IAi,lli%' A CA 92231
{fii91`+hA>Ct7^`� t-'�1,i�155
USE OF PERMIT
t-�<yN.aEa
YLs•.31 CAN-. V, iy ' i l>vw't the 1^`
AM.Vj O SPA. �,iii�tl.t 1.3
'i
iTHUC
ESTINIAIEDD MST OF CUMS T! ON
pi_.AN CHECK FEE EO1-000-439-318 $x_100
t1 t9-()f)O 0-fo
°O'f STR [��(°'c-�Y 4 JIT. 1
y01-(1�fV-4q p$S{
ca I:rITMIp .""L FEE '^ POOL 1.V 1`000.420-W0
l�f:tlf�'iTlCtrft:+• i•'�--1'#.:1��.L :till-Ochi-�it�-tif�i �27.tia)
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SiJI?M:Y'lW, f`ON,KC'Ra.i(:TION AND PLAN {.'JAJT�.
41410.Sf)
1.,E SS .PRE- r &ID FEES
to.orl
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Under" round Ducts
Forms & 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping 4kWl 511
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
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Futures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: