0011-138 (BLCK)LICENSED CONTRACTOR DECLARATION
.1 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
Al. 4 V?
11B__7
QSignature ofContractor
:Date
OWNER -BUILDER' ARATION.`
I hereby affirm under penalty of perjury that l.am exempt from the Contractor's
License Law for the following reason:. . .: .,
1, as owner of the property, or�my e'mpl6yees with wages as -their. sold
compensation, will do the work, and the 'structure is not intended or off ere:d.for
sale'(Sec. 7044, Business & Professionals Code).
1, ' as owner of the property, ' am exclusively c6ntractind.with'licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). J
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 p4rjury one of th . e 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 P014 No.
STATE MUND
(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 ma-h-n-er—s-o"a's to become subject to the
workers' compensation laws of California, and agree that if I shp
_g1dbecome,
subject to the wotkers'.compensaiion . provisions of Section 370IT6f�-h Labor
Code, I If/ A -,p sh4ll forthwith comply.Aih those provisions.
Date: Applicant—
Warning: Failure to secure Wo'ker§' i' Dompensatior� coverage is unlawful and
shall subject an employer to criminal penalties and civil fine,% up to $?diy:000)in,
addition to the cost of compensation, damages as provided for in Section 37 6
of the Labor C.ode, 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 pe rson 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 abov ' e information is
correct. I agree to comply with all City, and State lawsi relating to. the building
construction, and hereby adt-h—?r-i*zerepresentat-i�ves of-4his City to enter upon
the above-mentioned property for inspection pu0p
Signature (Owner/Agent,� bate
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS
RMNC-110 LA QMM.A DR -M
OWNER CONTRACTOR/DESIGNER/ENGINEER
SPAR.1111.19 CONEKRUCU)w
sp WA cammucriow
19-2,95 RAHMO 1A QULNTADR. 7 153k -M RMCHO LA CWIMA DX
Uk QGNTA CA 92253 1A. QUIPTM CA 92253
(7 -60.)?l 1 w 194.1 -CM-0 2996
USE OF PERMIT
0- INIZERAL MAUMR')
11�000 LF X 6- MRDIrW -WAIJ, - ORCO SYSTEM
6 F T. NVA LL
%0(16,00 ua
W TM
) - &AIND C09r OF CONS M(MON
PMUr.r ME STAMARY
CONSTRUCT104 RM 101�000-43?400 M9150
AL COMWERUM30H AND PLAN CHO=
PYRRMITFECE-S DWRE
RECEIPT DATE BYI INSPECTOR I I DATE FINALED
� t. r , .. . . I . .. . . I :. .t - 7
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
Underground Plbg. Test
Final I I
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
COMMENTS:
2-07
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66 /s y v ,� S� �� a' AJ
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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)