0104-023 (RPL)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
656128 Q753 HIC J, le 4 101.11, 014
Date may, Y49 Signature of Contractor
JO
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).
( ) 1, 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 isFued.
( ) I 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
.. Policy No.
STATS ryry¢P24
I 040
9.6AH3
(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:/J' Applicant I f- fJ /� '-�✓
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 above-mentioned property for
inspection purposes.
/gnature (Owner/Agent) �)� i /�'=�` �^'>• Date
-
BUILDING PERMIT
DATE VALUATION LOT
iB.f.•�PA J:'iJR.l�tdRJ
JOB SITE
ADDRESS
7 -'5 VAYA
ER
ITIMURIT .vW 1, C OMAK xIIIES
15.3530. T11 WREFT,1r".m 0200
IWIT BMW:st RINNO CA 97AOS
USE OF PERMIT
PC�C:LAWDOCYR. �'.fa,.
PERMIT #
0104-0.13 TRACT
4-7
APN
CONTRACTOR/DESIGNER/ENGINEER
r_'AT.ZD1MU100LS KPAS (-MP MAN'
PAJIM DMIXf CA 92260
(76OX440-9000 CRUI, 355
rPWIAPA.. »b;'fA13'MS1BARR3'3 RS ,`S'K€aLL 89, PLACE AT PI ,PLASTER
INSPECI'1M 1119 .t..f. OF 4' HJ014 SLO(% WALT, CITY STANDARD-
1m1XMMUOR `M
4 FT. WALL
20,00A U)
MOO OO iL F
Sra"T ) COST CSF! C43i`dSTIRTIMO 20,1 M-00
PLAN CHWK T'� S, 103 -WO -439-318 $140.40
C014S`d`RUrCTICH .FEE 101-000-418-0,00 $216,00
'8 R-C1BANIC AL ?E*F,, POOL. 101-000421-000 $24.00
f'?'t,,i i;TRff,".AL P69 - POOL 101-000-420-000 100
DU U019 PRE '-1'IUD'ir,f.:.F�,� $0.00
APR 4X01 ' ..: hIM FE- ]YIDE'Now $452,AQ
CITY OF LA OUINTA
FINANCE DEPT
RECEIPT I DATE i , BY IDATEFINALED �_ INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I 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
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
Set Backs _ _
Footings _ L_� �i�'
Electric Bond
Main Drain
_ ll
b
Bond Beam _
Approval to Cover
�O
Equipment Location
Underground Electric
Final �/ �`� .
Underground Plbg. Test
Gas Piping
PLUMBING Io►PPROVALS
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub P0nels
Exterior Receptacles
G.F.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)