0010-103 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury�that l.am licensed under provisions of
Chapter 9 (commencing with Section 17000) hof. Division 3 of the Business and
Professions de, and my License is in full force and effect.
License # l 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:
( t,) 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 orooertv, am exclusively rnntracting with lironri?d*
contractors to construct the project (Sec. 7044, Business & -Professionals "
Code). "
() I am exemunder Section , B&P.C.1for this reasoan.
to ,/+� - J taSignature of Owner. l"t}C„� 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).
(.) (''certify that in the performance of the work for which this•permit is issued,
1 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 to4he workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with tho e,provisions:
Date: LT-') -6k Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. .
IMPORTANT Application is hereby made to the Director of Building and Safety;'
for a permit subject to the conditions and restrictions set forth on his°
application. ,.
1. Each person upon whose behalf this application is made & each person at' a
whose request and for whose benefit work'is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if'�
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. .:
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon.,
the above-mentioned property for inspection purposes.
si-R
nature (Owner/Agent) .,_�� �'• �=' < Aate,LD
BUILDING PERMIT PERMIT#
DATE , VALUATION LOTTRACT
JOB SITE
APN
ADDRESS
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OWNER
CONTRACTOR/DESIGNER/EN (NEER
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IS.1`110 R.Ot.'`.%RT-MY.' C:t3'URT
76"710 R01L''3 Fay Co't?wr
Ir's•� q, l'1,L�+.1�',f� CI A2253
L�A.. Qvlw,rj1 CA 97253
(76?, 0050.61 D CU4.
USE OF PERMIT
9f L,nti X V Q¢x14DYMN 'Ki$U WITH AR01(CITY 11TA.MD RD) - 60 LF X
14 OAS 108 FOR F UTUMV, POOL
'tTAL1i'1?A'IION 1.5
.
'_5 FT. WALL 51.0 LF
AMD COU; OF �'rC�1+I�a".&. C.-'�`ION
11204.15
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CONSTRUCTION 70f 101-000-418-000 00 1. 00
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$69.15
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION* RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
S ,Backs
Underground Ducts
F6*s & 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
BLOCKWALL APPROVALS
steel
POOLS -SPAS
Set Backs
Electric Bond
Footings
Bond Beam / (-I �'.�p /L,(
C�
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
_
Final ?)'r,21a� C1����
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric Final
0 `7? hof C07 -12K,
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lav Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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