9910-155 (RPL)8 LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
1� Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
W1 r Professionals Code, and my License is in full force and effect.
O M L'icen 4 Lic. Class Exp. Date
o U.) Wrs C53 C27 B ZO&30rm
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Z /ate�' Signature of Contractor.., _
CSO o Oma_
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F— ip OWNER -BUILDER DECLARATION
LI hereby affirm under penalty of perjury that I am6x,/empt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
M
a Z WORKER'S COMPENSATION DECLARATION
C, < cc I hereby affirm under penalty of perjury one of the following declarations:
LO FZ O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X UJ compensation, as provided for by Section 3700 of the Labor Code, for the
Om _ Q performance of the work for which this permit is issued.
Q I have and will maintain workers' compensation insurance, as required by
O C) Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
4 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
CarrierPolicy No. ry
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Q (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
work rs' compensation laws of California, and agree that if I should become
subj6ct to the wor rs' compensation proviVons of Secti6n 3700 of the Labor
CAe, I hal comply w, -th' a vi ion
tate: Applicant
Warning: Failure to securg_W.ork s Compensation c erage is unlawful and
shall subject an employer to criminal penalti�and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct, I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
th bove-mentioned property-fsinspection pur ores. y
ignature (Owner/Agent) Date
BUILDING PERMITPERMIT#d��
DATE VALUATION lii�li�i LOT TRACT
JOB SITE 7$.M .WRUS
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SI YE MT HOMES
DATE PALM ENI'IrRPRISES
3400 CENT RAL AVENUE b`M, 32 ►
81.905 MOUNTAIN VIEW LANE
RIVE KS11+ CA 92)50b
LA CIUINTA CA 92233
(760) 44R- i 7f+(i C.. RL# I iilili
USE OF PERMIT
t X)L AND/0k NPA
P(X)L is SPA 0?&Y. ALARM&R RltKILS SHALL BE IN PLM' AT
I►ltb-I'LA.`3"I'�:it IN:Ii'hi►."I'!C►N.
PC KA, AND.'f'1r '91A 15,W).00 LS
ESDAU'fED (=T OF'IDONSTRUCTION
15.M.00
PERMIT FEE SUMMARY
PL AN 0 iPX'K Ham? 101 -dt00 43 -318 S105.30
")NSI TRI W -V (')Ai FFF 101 -(XX) -4184)(10 SI62,00
1618CC71ANICAL FM -- fr)OL I0I-000-421-040 S24.00
&.&: MCAL FM -- P(X)L 101-000-4220.000 34&00
PLM040 kim -- IN XX 101-bOO-419-000 527.00
Y, in- fY' Ai.c'f;lTv�:iCi.f I(T!r)N ANI_) P1 -NN I'11VCK
$363,114)
LES' "Rr 1►All:) FEES
P fX)
101AL PENMl`[ kl':F8 014*, NNW
sj"."
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
- o
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
p1L. Gcf 148�_
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
OX 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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: