9612-003 (RPL)U)
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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
/ '574 12
.7 A 813 1 M
Date 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:
( ) 1, 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 & Profession als Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Profess.ionals
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.
S�I have and will maintain workers' compensation insurance, as required by
Ct,on 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:
Cartier Policy No.
STNrli, F UND 1 �4 24711V5
(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 it I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
C.0de, I shall forthwith comply with those provisions.
Date: - Applicant
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
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
t,he above-mentioned property for inspection purposes.
Signature (Owner/Agent)
Date
PERMIT # CONTROL#
BUILDING PERMIT 1612.043 4434
DATE I ?J :I/fg; VALUATION $16 '000.1)11 LOT ACT
JOB SITE APN
ADDRESS 79-3241 C"11NIOROSM)A 604-19Z-010
OWNER CONTRACTOR DESIGNER ENGINEER
'VY 10N
z4E !' DODSON CMMRIUM
79320 C KWA1N0* ROSADA 08NSA PE ,Z Rfl HE
LA QVfW_A C'A 92r2 .53 CATIC-DRAL CI[TY C A 9 22".1 it
2132 , it
(61 1�)324� 1 CRU 1044
USE OF PERMIT
PW1, AM)IOR SPA
VAMAINVIC.P.4
14.00A LIS
F* ?9 COS�"C)V S1 ft(J(.'4' VtON
'31,11
fe
FICIP, "Swim NfARY
PLAN C34f `�CK FVN 101-000-439-318
i70II4
IMICAL Frli - - T'00f, MI -000421-000
A0 00-42"
J� K)OL I �`(J .06 s i.w
I-', I "C ' ZWRON AND -MAN M41P.CV.,
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1, ES [U.TAIO FEES
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TOTAL11KRAUT FERSIAWN4,0111
RECEIPT DATE BY DATER ED/, INSPECTOR
$�-7R 15
$0.00
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION
I DATETINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
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
E)derior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
Set Backs
Electric Bond
Footings
Main Drain
I it /YJ6
Bond Beam
Approval to Cover
U11 111
Equipment Location
I I
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
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
Vxtures,
Win Service
Lub Panels
EAerior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: