0111-161 (RPL)LICENSED CONTRACTOR DECLARATION
]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
45�
/_ / � L53 fi�d1:� S i2$
Dat Signature of Contractol',•
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), �.�1P v
( ) I, as owner of the property, am exclusively contracting wltt' 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 issued.
( ) 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. 046-01001040 '
(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
subjectAo.the workers' comp sati�on provisions of Section 3700 of the Labor
Code, h II foh ith comply wi those provt ions.
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 Sects} 3706
of the Labor Code, interest and attorney's fees. fl� 1D
IMPORTANT Application is hereby made to the Director of Building anety.p'
for a permit subject to the conditions and restrictions set forth his' IV(
application.
1. Each person upon whose behalf this application is made & each p rso
whose request and for whose benefit work is performed under or purr uant to Cr
any permit issued as a result of this applicaton agrees to, & shall,,in ramify
& 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 pr ? F
p y for inspection purposes.
Signature (Owner/Agent)-" Date��*'o°�
BUILDIWOERMIT PERMIT /f
DATE VALUATION. LOT,g TRACT
_
JO& SITE APN
F
ADDRESS 79^420 PM .90 PFI,,RF.e
OWNER
CONTRACTOR/ DESIGNER/ EN1NEER
1.811gqrr.70J_1 Hrtltl
p+03 lat,?00 .2 & dPAS
79-4-20PA`a"1?C DM, RXY
PAMA A 1791
1..A QI IRI -A CA 9225',
LA CSX rOT.h CA. 9225.1
(16A)360-3585 C` 10P I t-)45
USE OF PERMIT
KOID..14"PA. ,Ot.LA.r< MSM-kPAIERS'SNA .L BIR IN PLACE AT PlMPLAS!'I?p2
1'KSPECTIOX POOL SNO(AXitAX NOT INCi,,l`3'DRD
11001..FiNL" OR SPA 151000.0 x.1)
,aRiUMAM C, MC OF t'ONSUROUXEON
1510001W
PLAN C3.3:F.'.Cr. FU 101-000.439-318 5105.30
C ONS T ,4tUCT1f:)14 PUB 101-0004M-000 $162.00
l;'IS�Jx—f1001., 101-000-421-000 42+9.00
'Y,�tEWt,.ry;Hep1y4�NICA'L
y'i..4MVl+ 6'A\.��i.R'1:6V �fl'u a� 6'��:Rh+� A � b �F���6�d5!�"•tJ4Q �:S.YV
1').itb:PABINO MR9 P0,010 101.000419.000 $27.00
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U,S PRE-PAIID A—
$0.00
WfAL PERIM IfTES DIT& PiOW
4
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
Steel
Electric Bond?-��9
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
th PLUMBING APPROVALS
Gas Test
/Z ..o 0,;
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
n�
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
_
Gas Piping
'Gas Test
Appliances
Final
COMMENTS:
Finah
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring -
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
-0 000
o
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