0107-212 (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 w.ages"as4their 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 protect (Sec. 7644, 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.
( ) 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.
STIVY FUND
(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 provisions.
Date: Applicant
Warning: Failure to secure -Worker s''Compensetion coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the costof compensation, damages as provided for in Section 3706
of the Labor Coder;; nterest 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
t the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
. BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 1,94363 CA -UR PALMIKM")
I
OWNER
CONTRACTOR/DESIGNER/EN (NEER
SMS. Lad; t ATRICI C .MCi09
a'. If. P100L COW �lRU,(T1 1:00
f~,7Y3WA CA, 92253
GFML13:12,f L M'Y'' CA 92234
(760)328.7515 CB114 69
USE OF PERMIT
Pe')C?L.A14rV(?R. 55 �
PODf.ARA.,AiA.tt_AW-BAPIW ri.R, SfiA.LL BE IN PLA(.`F .AT P1;' -i PLAb7"Lit.
}9L'PECTI.OJN. P0010 SQljJVPMV9T EXCLOSUIM wolf MCLUY)FID,
T,001,.AN f3POR.111A 12,900,110 LS
dWMM"TdCei)'MET OF WwbJ'NSTRUCIIATOi-,'d
12,50D.Si0
BEAN { HITK FSE': 8 $93160
CON,2 r itiUC`I'ION FEE 101.000-418-000 $144.00
9.9t;H1'a1r31C"AL'YU"'• ,..,PL'1nX, 101-M-"21-000 'SAA
-000
j"l.E:tr'['Mf;;M, FFY, - ,i'E2OL 101-00"20-000
FL'UMIRI 0:1Y+V — M 101.000-419.000
i
1l 1t
CYCt'1',Ci'21'�
OF
RECEIPT
DATErf P
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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
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
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gasas Piping
Gas Test
Electric Final
—
_ D, ��/
(✓ -�
Final
PLUMBING APPROVALS
Waste Lines
Heater Final
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 g/Zo/� j
C_
Gas Test
Appliances
Final
�/
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COMMENTS:
/
Final
Utility once (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)