0309-096 (RPL)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
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:
( ) 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
cdntractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exeMpt tinder Section , B&P.C. for .this reason
Date 2ZSignature of Owner :n • u r r.•„ !
^ I
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.
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those p"rovlslons:'
Date: -0/s Applicant AA.°� �iyt
% i H j y
Warning: Failure to secure Workers' Com pen sation;c erage 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 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 purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE { VALUATION L0 Si.�i�?!r, i TRACT
JOB SITE
APN
ADDRESS
4t
7 R /JJ+ ♦♦ 0MRy 1 )OR
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1.AQ*1r1TA CA MB.t
R i .• . �.''.?L.N'.
USE OF PERMIT
1?�FCyf,l'.s"6',� Eii3(� ('1i:a .►:s:n• f'€d�:d��, �:1.�,.IP�t�•i:k<.PiA.taf:�:.: �; :•;� €Af.,J, itF,� rr(
PLACE AT PRIE 'WqPizt"'!'IOR g. F•tdCU'liLd.R 140T
rucir.sfr�:�s°,
POOL Ti� Ls
i. 4 'xWL1i"G7:iY (110W. ia%' : M11IFx11RLGMON
/ ��'I�es'n�`��.li%t'iyi �. ��i�-/V��c�, .[f.�ylfnf'l�1�:{! �llop.•�L 1r��}j{t
^��L.I.IY
�`y+•`,�{LI+
f':t%l'3'f;i"7'lf7�ita;ft�i:• 'trl"4fVV'�l1Gf"•1(ISS� ��JY.VO
E,,1,Zt{'..'1 V.1CA0., F&4" r ::?i. 1c.r �A5.0
PGllYd BINO F -;1=, ; ;� �if(1ij,� 1�'•t3J('� A�`f,pb
D a
14
SEP
SEP 151003
CiTpAOF . �q QUI
RECEIPT TE _, 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
OX 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
t,
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
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
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
— $
Gas Piping
Gas Test
Appliances
Final
R- nal
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:
PEBBLE COAT INTERIOR FINISH, WATER FEATURE AT + 32 '
AND STONE WATER UNE
rvv'UDEIS TO BE SELECTED • _
RAISED SPA AT Zp WITH A
p/�j SPAMP STAIN CONC: CAP.
16' WIDE SP
AMPED �— _.._ 8' INTOE STACKED STONE SPILLWAY,
STEIN COLO TO BE S N�E1E STONE FACING, FINISH.
t ELECTED..
1 r
Num
N1sl
BBQ � • • •
EXISTING WALL-
DUSTING WALL
w
�
Y
�
'.t , :'�
/i
/ - `/�
i.s
/� �,✓/
Z'f X25
\0VIALL TO MACH
.......
.. :. :.:. .. ....... ./....'
/
// irk.
A-..moi
1NG SAME FINISH.
&SPA y- -
*,,,7 9•�J?.6L
174.,
'HENT � � -
Cb"T 1 � �
• • '
Num
N1sl
BBQ � • • •
EXISTING WALL-
DUSTING WALL
w
f
d q ) CITY OF LA QUINTA SUB-CONTRAC)rOp LI T
JOB ADDRESS / �A[ho o, a71. PERMIT NUMBER ��%3�%-0 OWNER BUILDER 04,
This form shall be posted on the lob with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to ti lis list must be approved by the Building Division prior to commencement -of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each 1pplicable trade, all information reauested below must he rmmnietPri hu nnnlinnnt 91nn Ciln^ ie nr,t ,..,,....,.---
EARTHWORI( IC -12)
CONCRETE (C-si
FRAMING (C-5)
STRUCT: STEEL (C-51)
MASONRY (C-29 j
PLUMBING (C-36)
OTf"LASTER 1C35).
DRYWALL IC -91
HVAC (C720) .
ELECTRICAL (CAO)
ROOFING (C `391;:---'
SHEET METAL`(04il:
FLOORING (C-.15)
GLAZING (C-17)..
INSULATION'(C-2) ;
SEWAGE DISP. (0-421 .
PAINTING (C-331
11 CERAMIC TILE (C-54) I
CABINETS (C-6)
FENCING (C-131
LANDSCAPING I6-27)
11 POOL (C-53)
Conheator -.
.: : .. State'.Contraclor's License . >;: : c
r..: WOrkErs'Compensation Insurance
Ci .Business License.
Company Name
Classification
(e.g. A, B, G -f))
License Number
(xxxxxxl
Exp. Date
(xxtxxtxx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xxlxxlul
License Number
lxxxx)
Exp. Date:
(xxlxx/xx)
i
1
� H
ji
i tt
j1
• .i
'. Cr
-s3 c8
le
s
OW -P9094
r