0207-191 (RPL)p ( LICENSED CONTRA ECLARATION
I hereby affirm under penalty of perjury' licensed under provisions of
Chapter 9 commencingwith Section 70 ision 3 of the Business and
Professionals Code, and my License`Ps'irhf Tforce and effect:
License # Lic. Class Exp;*Date
a z� C$3 B C C-3 10/31M
Date - Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby, affirm under penalty of perjury that I am exempt. from the,Contractor's
License La'w for the following reason: ' r
( ) 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
performanne of the work for which this permit is issued.
t) 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 S- T.&` p t;OM1'F.1� P' I Policy No. ''0460006,162. 1
(This section need not be completed if'the permit valuation is for $100.00 ordess).
() 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; l 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 oost of compensation, damages as"provided for in Section 3706 -
of the',Labor Code, int6re'st'an6attorney'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',, ii VALUATION LOT . TRACT
JOB SITE DDRESS,V • - 9470 .UMCHO Q11 A RIVE
APN «
OWNER
CONTRACTOR / DESIGNER / EN &NEER
T.D.IF Sit<U DEVE{.:.4;➢R�11
CALSY014TIAPOOU &WA9 �`.l"0P Mfi"N C -0i
'PI O. BOX 17 16
747Z's MAI DRM ST.1Ti'1r 4A
LA QUID1`!A CA 922153
PJALM DEW -T (..:A 92760
USE OF PERMIT
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POOL .daN NOR VA 24M. 00 IX
MAW= COFE OF CONS'.t!'42AIMIGN,
PLAN CHECK FE
0014 5 S7[R UC T ION PRE, 101-000-419-000 -000 $30.00
14,M1- IC A.t, VEIIII "• P006 101-000-421-000 S.2a.0
r LEVMCAL ERRSPOOLt�q • a•�: - of� .too
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IYERMIT I'KES DVE, NOW
507155
CITY OF LA QUINTA y
FINANCEDEPT.
RECEIPT
DATE
BY "t} f_- ''
DATE FINALED
INSPECTPR
Ili
tT^
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
Ir
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
arty Wall Insulation
Condensate Lines
Warty Wall Firewall
xtenor Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond �G—
Footings
Main Drain _2
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test 2 T.
Final
PLUMBING APPROVALS
Gas Piping — . 9- .2i!
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 ,ZAs
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: