9910-100 (RPL)LICENSED CONTRACTOR DECLARATION' T
a,e-I hereby affirm under penalty of perjury that l'arri licensed under provisions of
.:"-Iapter 9 (commencing with Section 7000) of Divisio -3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
2917.25 : 00 .1r20i
�qte—..�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 licened
contractors to construct the project '(Sec. 7044, Business & Profession Is
Code). (�
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner 1
WORKER'S COMPENSATION DECLARATION.
I hereby affirm under penalty ofperjury one of the .following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compens tion, as provided for by Section 3700 of the Labor Code, for the
pe, r nce of the work for -which this permit is issued.
( I have and will' maintain workers' compensation' insurance, as required by
S ti n 3700 of the Labor Code, for the performance of -the work forwhich this
permit is issued. My workers' compensation insurance carrier & .policy no. are:
Carrier Policy No.
STATE FLMI M-99 31141 n NW49-1
(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'provlsions. .
>116': zr.., AO& , Applicanti!!!t.r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up.to $100,000, in
addition to the cost of compensation, damages as'provided'for in Section 3706
of the Labor Code, interest and attorney's. fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon.whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify.
& hold harmless the City of La Quinta,,its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the ab e -mentioned property for inspection purposes.
ature (Owner/Agent)"-" '�-� . sae Datek`Z 7 �+r
r P
PERMIT #
- --- r' f
BUILDING PERMIT
,
DATE V VALUATION ,i�0lt.tlb� LOT 'TRACT c1 p {r',.'#4�
lag
JOB, SITE
ADDRESS 53-330 AV7"N10A.RAhiEWZ
APN'
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LA Q'JTNT,'k PAl'.'j'I E S
Wi1.;LiA?d .R1.118S1?1.3. x.00' -R.S
51.3 i0 AVENWA RAUWDES
369W JACKSON ST
LA. QU!"tN T'A CA 97.253
THERMAL, CA. 92,174
(7(10099-11130 C13 a- 1354
USE OF PERMIT
POOL .ANDOR SPA.
POOL ONLY. Al. ARlfi&BA%tttERS SWUI SE IN MACE ATI PRE-PL.ASTE"I;c
PI iOL .t1,,v1XO SPA, 1,$
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aYgi7��,1�
��1���FT 9�,"� ��l6�•1��:A:�'fr,'
P 1,AN (:'•HE(:L FEE $61,:35
LONSTRI ."FIO'N FEE. 101-0160-4184M 109-0
INIECHA 11CA.i,. FFM -- P(YJL 101-0011-421-000 MUO
E1Li:, ,l R C;AL F -- F.'t)* C 1, 101.0.00 420-Wi)
4n.l.ttilQJfNG.1_,EE_-Pti023, 1131-000-419-000 SiBl.Oti
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StJB-I'OT..AI. Cr)N&'YT?.1,To"nOtN AMr.) PI.,A.N C'.14EC I3 .
$259.35
LESS 1aR3r••P V- D FEES
$41.011
`9°t:)"ti,•AL S'ERM:IT FE.ffe',.� DUC' NOW
RECEIPT
DATE
BY���
DATE FINALED
1e2' f f
INSPECTOR
-d
c'
INSPECTION RECORD
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
{
Forms & Footings
Ducts
t
Slab Grade
Return Air
i
Steel
Combustion Air
t
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
{
Framing
Compressor
I
Insulation
Vents
I
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
i
Party Wall Insulation
Condensate Lines
i
Party Wall Firewall
I
Exterior Lath
Drywall - Int. Lath
{
I
s
Final
I
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set BacksElectric
+'
Bond
,
Footings
Main Drain
{
Bond Beam
Approval to Cover
Equipment Location
4 S
Underground Electric
l
Underground Plbg. Test
_
i
Final
Gas Piping
'7 AID
PLUMBING APPROVALS
Gas Test
{
Electric Final
{
Waste Lines
Heater Final
{
Water Piping
Plumbing Final
{
Plumbing Top Out
Equipment Enclosure
t
Shower Pans
O.K for Finish Plaster
i
Sewer Lateral
Pool Cover
i
Sewer Connection
Encapsulation
z
Gas Piping
I
Gas Test
i
Appliances
Final
/ 2_=jv_., f Sz
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 (Penn)