0003-256 (RPL)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 `(commencing with Section 7000), of Division 3 of the Business and
d
NUJ Professionals Code, and my License is in full force and effect.
O =) M License # Lic. bass Exp: -Date
Lu It
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oZ r— ��i e %� 1� Signature of Contractors �'� `� �!
O
6 _ 1 f
J U C) OWNER -BUILDER DECLARATION
WUJUJ I hereby affirm under penalty. of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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
LO
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
IL
C) Z I hereby affirm under penalty of perjury one of the following declarations:
r O () 1 have and will maintain a certificate of consent to self insure for workers'
X W I= 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.
C0 Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q section 3700 of the Labor Code, for the performance of the work for which this
L L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Camer o•r-n•ry- Policy No.
3?
41 ,YVY
C)
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(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 ik1l should become
3 subjectto the workers' compensation provisions of Section 3700 of the Labor
Co a I,sh' Ilfoithwith comply with thio§e�rovisions. 1 {
Date: i,t,/L?� -Applicant j 1\ � ``�
Warning: Failure to secure Workers' \Compensation coverage is unlawfull 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 purpose's.
Signature (Owner/Agent). ate
BUILDING PERMIT PERMIT#
r
DATE r�VALUATION $21.000.01 LOT 117 TRACT .2891
JOB SITE -% •j. yV4.., LAI, Oktk�1��
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'I'n T"T,S
1.-. . l.w 1 1 ! a, 1. ji •1 1.
i� A
I"t1I ! (1T.i1� r?!�(1t C.(
•1 \, \1 i 1A 1.) ±
rr"O BOX 17.16
74-725 j0141 iir".IW, iilk
I,A QUIN'1'A. CA. 9222-S3
11ALIM. 1)E'S I -XI. ISA 922oO
(lOO)iQ-9A1}t! c:iL.tl 1996
USE OF PERMIT
k' A:h, ANUOR SPA
K�OL& SPAS Udl ctI 2 WRIER Fr,ATUktr:3 & BF1Q? AL A_KNiS%Ai(RIE,RS
`HALL BE IN KAU,, At' PIW.-P AS'I'3st2lN;i1?L:CTION
VALUATION Z 1,W0. W L 3
'll��,!'�' A'A'iw 11 I['�C1T' li R� !'�(1R�t!"!'i)i tL'1'{'7'1•llii
I...7 i. 4d Ry.r+
0. Ll �1%l
9f lttTi:! t, /
PERMIT FEE, SUMMARY
P:LA3N CHCC K F.Ui $140.40
'
f;ow"I'l'}t1I(" ON. 1 6 E I�1_000-4 1 84!(1!I
11422 1121 '46V11ri11ys = -1 P010111 �01-00"C', •ALl 000 .n...•!.0
- � -
GLEC,'.EtZ i:AL FEE -- PCHM 1.01-000420-W111
PLUJM01'N< r ky-6 101-0000 19 -OKI $27.00
4d
8t11_1J Pr A1,COWISP IiC."1"1IlN NID'Pl.ANc.9rj K
1120"S PRE -PI AID HIS
SO.na
T Y!AI, >i'ERIN'11.T £+,:LiK,1011;x, NOW
RECEIPT
DATE
BY
DAT
INSPECTOR
1
_ACED �v
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
j 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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
cc/
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
CGs
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
C/
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 (Perm)
COMMENTS: