0107-135 (CP)1 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
Dat- f '� Signature of Contractor f 44 -
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).
( ) 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
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.
(Y ), 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.
STAU? 'f � i C+4tit8 t�ktj aft+
(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
subject to the workers' compensation, provision's of Section 3700 of the Labor
Code, I shall forthwith comply witr�iho`se provisions. 1 7
Date- '' r Applicant ((a'�, ' le
AllF
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 3706v'"
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.
t
1. Each person upon whose behalf this application is made & each person atr
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 andstate 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 foiinspection purposes.
Signature. (Owner/Agent)IR4., f�} i � `D
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BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
JOB SITE APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN (NEER
1_1 Q BOX. 17 16 74-725 J0H_T'DrYVP�ftA
Lh O'C3X7,`A CA 9225: PALM DE',TYRT sr';A 92260
Q60),140.90(0 CB14i, 5386
USE OF PERMIT
P001, AWDfQR .04A
CO>kPM RK:AL PF,BU &. SPA ONLY-AIARNIMAARIEPS .SH ALI, BE YN PLACi,'
AT FRF. PLA611 P,1AI14P`f0X,P00L XQUIPM'EN,tTSCMC.�Y, KE 39 NoT
POOL ,/A.Y3MR SPA,
21)1000.0 W
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:tiUM C1- VIX RrIly, 101-000-439-313
C0148MICTION 'PE t t 2 -Chit i.2ti-F ( $ 6+.00
MECIKKNICAL I'VE - I. POOL 101-000-421-000 T14.00
91=71MCAL M. — 17001, 103 000-420-000
R:U'k'i>}31110F.C. 2 — POOL 101-000-419-000 WI WI
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L CITY OF LA Owi fA
FINANCE DEPT
RECEIPT DATE BY DATFI /AO 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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Footings
Bond Beam
Electric Bond
Main Drain
Approval to Cover
a_ ,lJr
Equipment Location
„r
Underground Electric
Final
PLUMBING APPROVALS
Waste Lines
Underground Plbg. Test
Gas Piping
Gas Test—
Electric Final
Heater Final
C/ 2
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
�Z ��� I ��
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)