0402-382 (RPL)LICENSED CONTRACTOR DECLARATION
U I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with ,Sectioa_�000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O =) Cn License # Lic. Class Exp. Date
UJ
0 3.2f54 C5 31LCi30�5
oZO � Date Signature of Contractor
F- � OWNER -BUILDER DECLARATION.,,-'
HLU I hereby affirm under penalty of perjury that I am exemp zt from the Contractor's
U) License Law for the following reason: �� k
Z ( ) I, as owner of the property, or my employees with wages as their sole
compencatinn, 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). ,
C0 () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
d Q WORKER'S COMPENSATION DECLARATION
' p Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y: compensation, as provided for by Section 3700 of the Labor Code, for the
O _J Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
OL Q Section 3700 of the Labor Code, for the performance of the work for which this
CL:
F<:
permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier�., Policy No.
cb =) STATE Ft3-.iL� 16.4$04-03
�p
J (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 Cal'fomia, and agree that if I should become
1 subject tojthe workers' compensation rovis ions of Section 3700 of the Labor
f`•77 Code, I shall forthwith comply with those provigi S. .
/Date: 2—h Applicant-
Warning:
pplicant � � f
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. Ir✓
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
above-mentioned property for inspection purpo�_Y Z
Vhe
gnature (Owner/Agent)
Dated "Y
Y
BUILDING PERMIT PERMITk
DATE./"��, VALUATION LOT 0402-2 TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
'iH( dAs BTA"MR
0.3.71"780 7100L P.L'C7Rti13ING,12ZC
:R0, BOX' 134
6fo7 7:"V6 7 IU).
IA.QkRNTIA CA 92253
PALM SPRWGIS' CA 9226-1111,
(7mp2v7592 CrBL''A 816
USE OF PERmli T
P06i:. ITA/Olz 119P
POCIUS',rPA 138Q(A61-4 1 ,41.5 i",I$951 E:LA.tl.t2,'.vrMRRMRS To Or, 1'�1
PLAC 9AT PPS -PLASTER INS PrOTION EQUIPMP-14T YFl0A0CfEt?i NOT
Ip3f�LulJ.
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CONSTRUCTION FFIE 101-000�418_000 $199.00'
1490 ANICAL M •- P: vL 101.000.421.000 $24,00
?;'L�£:'l'(�'i L YMPY, ,," POOI� : +a A -O:liJ =� 20-000
PLUMr;tlN(I FU -• Pool, 101-0004119-000 R53,W
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R�•Ay /+� �y,y ��ry�p
p � AND
F.dIR-T lA AL CO'MPS.t.3CL�!a.i.l.d.0.i.� J• ND 8`J.�"fd�7 CIMOX
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Cliq/ OFFINAN
LA OfBiPJ �y
RECEIPT
'DA
L�/'
BY `
DATE FINALED
L
INSPECTO
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
7
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
3
Equipment Location
Underground Electric
Underground Plbg. Test
'
Final _
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plu';rbing 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:
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)
CV -
m
(.4
a
Construction is NOT PERMITTED
on the following Code Holidays:
New Year's Day
Dr. Martin Luther King Jr. Day�;
President's Day 1.{ '
o
Mei orial Day
oIndependence Day
o
Labor Day
N Veteran's Day s.
Thanksgiving Day 3 D I eirp
Christmas Day
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