0012-078 (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 % - f /�� Signature of Contractor
OWNER -BUILDER
I hereby affirm under penalty. of perjury that -1 am exempt fr 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
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 ofconsent to self -insure for workers'
compensation, as provided for by Section3700' of the Labor Code, .for the
performance of the work for which this permit is issued.
(J_ 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:
CarrierPolicy No.
(This section need not be completed if the permit va uation 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 end agree that if I should become
subject to.the workers' compensatlon,provislons'of Section 3700'of the Labor
Code, I shall o with comply with those prtovlsions.�,
Date: 7� I Aoolicant """'-��"° -A- t
Warning: Failure to secure Workers:,Compensatio%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; damagesas 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,foringpeciit purposes.
Signature (Owner/Age t), Y�'-% Date
J -
BUILDING PERMIT PERMIT"
DATE VALUATION LOT 00A,1+ 0 Iff TRACT;
-
JOB SITE
ADDRESS
tO-6W CAiJX P'ALOM A
JAPN
? di3`i 4�gAI
OWNER
CONTRACTOR / DESIGNER / ENGINEER
BCK U4ATJe:6 JJ&_ T GROUP
. I.��1�d G COTJ€IU I.LNG SERVICES
R0, BOX 14,90
P.CJ, BOX 5137'
LA Q-KANTA CA. 92253
I:.aA, QY.iM:k CA 92253
(760)771.2364 MIA
USE OF PERMIT
POOL. ANWOR RPh
SUPPLE hISNI TAi TO PEWIT 801-078, SH>°JWI.'@iC1 Cf-1AtZ 02 On
CONTRACTOR.
:'99MX KD COST OF C<0249MUMON
M150MILINNEOUR 101.0M423.000
..
It,
Z 201"
ff[iB=]'O'Da, CONZ.UC110MPa�,H) PLAN CHEM
$4.30
LES P'iL&PAID FEFS
$0.00
T(Y-FAL MCI= FEES DUE ROXV
$450
`y4
RECEIPT
DATE %
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 Wail 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
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
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)