9808-004 (RPL)LICENSED CONTRACTOR DECLARATION PERMIT# CONTROL#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT vN11J3�!!i 4
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION $64000. LOT TRACT '7 6
C14 W Professionals Code, and my License is in full force and effect. ( Q
License # p9 Lic. Class fixp. Date JOB SITEp +y 1 y' S*
O d /'� 634981 a 1J3iJ(1�D ADDRESS SM-15 A`V6a'�.fD3A i�i�:�tfMUDASLLI r APN
Z � yDate - %^ `:r !/ Signature of Contractor OWNER CONTRACTOR /DESIGNER /ENGINEER
co O U f`'�v r''0r'C.)P°Mn CO Y7RUCC RON r v���r��9�3. ' 10.Nr4''r' 1K r -'"��!0%N
r` F— O OWNER-BUILDER DECLARATION C is +' "''' Ci .iii `' ` " i" '"` "" `' U.e 1��.� ` `
_J U 5.1-540F,* i'SEN`f!C►�4`3?R i R. 51-540. iSENC-IU1x'EfZ i)R.
Wd I hereby affirm under penalty of perjury that I am exempt from the Contractor's LA, Q[1fNTA. Ch1. 92253 1.A QUIN!'A. C".A. 92253
C/) License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole (1C4)_1k4-4004 C1.3i.,# '22.61
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). USE OF PERMIT
as owner of the property, am exclusively contracting with, licensed POOL AN1WOR S&A
contractors to construct the project (Sec. 7044, Business & Professionals
Code). TOOL ONLY NO ITE.X Ei2. A`Lt�i�14'[SlrseliRRISR3 SHALL BE I14 ALT
co ( ) I am exempt under Section , B&P.C. for this reason Lauf-:NL1l�f'I'E11 fAf ffrE(",1'1C)�i.
N Date Signature of Owner W
O�
a Q WORKER'S COMPENSATION DECLARATION
or Z Q I hereby affirm under penalty of perjury one of the following declarations:-
O ( ) I have and will maintain a certificate of consent to self-insure for workers' YOU U ANDIOR SPA
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U I have and will maintain workers' compensation insurance, as required by
O U Q S6aon 3700 of the Labor Code, for the performance of the work for which this
� rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
I- Z Carrier Policy No.
Ob Ei��.f�1:iL ; 1�C�.t. 114ssl
J (This section need not be completed if the permit valuation is for $100.00 or less). CRUI# �' °`'I'iJMilftY
( ) I certify that in the performance of the work for which this permit is issued, PLAN CHECK FEE 101-000-439-118 $52.65
1 shall not employ any person in any manner so as to becpme subject to the (•ONSI'IRI;7r*"i' ON H1:L I.A! 0(1i,�-QIS-UUf� $NI,o3n
workers' compensation laws of California, and agreefthat if I should become E Fd'tICA4F03
•- POOL
O 1101101-000-11120-000000
JYt J.iIV
3 subject to the workers' compensationlrovisions of Section 3700 of the Labor
Codeel shall forthwith comply with=those provisions j -PUUM INO FEE " POOL 101-000-419-WO 127,00
/6ate: r6''r -� r 0 Applicant f 4,-
Warning:
, 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 SUB-TOTAL CONSTRUCTION All.) PLAN C:f;1I�C�. x+205,65
& hold harmless the City of La Quinta, its officers, agents and employees. LESS P.11' E-1'AW FEES $0.00
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 TOTAL PERNirt FEMME NOW $205.0
�,. permit, or cessation of work for 180 days will subject permit to cancellation.
r
lk , _ 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 a ove,mentioned property for inspect io purposes. RECEIPT DATE BY DATE tAr4g INSPECTOR
Ignature (Owner/Ag ne t)! . Date �•�/_-e
W
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
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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
G
Underground Plbg. Test
7 d
Final
Gas Piping
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final 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
I
Final
Utility Notice (Perm)
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'BUILWN,!-�; & l`,A',.'Hr.7-TY DEPARTMENT
ACCEPTED FORT CONST RUC TION
SUBJECT TO INSTALLATION AS PER
AND ALL APPLICABLE CODES
BY
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