0105-193 (RPL)LICENSED CONTRACTOR DECLARATION
kereby 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.
Licen9;'7 # Lic. Class ti Exp. Date
Date Y Signature of ContraGtor� — —_
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 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). , - , :y
O I am exQ pt�undeJ Section B&P.C. t�orthlsrreason
Date r' " " "Signature of Owne, °-- � .� i 1
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.
9" ��.°i'�.'�L3;�Rii '..',2�•tRD»n<�� x:3';4
(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' compensatiop provisions of..Section 3700 of the Labor
Code, I ;shalli forthwith comply with hose prw�isio, S.
Date: 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 cosi 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
the above-mentioned property for�inspection,ptlrposes
N
`�y(j yDate �� 3
Signature (OwnerPAegen.t)
BUILDING PERMIT PERMIT#
DATE LOT 0JCPS-19^ TRACT
ppVALUATION S pi yy pyo
JOB SITE
APN
ADDRESS
-940 A
OWNER
CONTRACTOR / DESIGNER / EN (NEER
:1.540 ANT. 1110AJ U
9522 DONALDSO J: D.
'A.qywrpCA 92213
L(3tv;XQ' W ALJ 14,Y CIA 923516
(7,60)248-6W, MIX 4.335
USE OF PERMIT
PC3i3L.,t'!IRWOR MIA.
PfiOZ,lWXYERF'.�VTVW.l •A).ARMM1J%PX1MV SE,AIJL BE IN PTAC:' AT
3 X1?, -;VLA %TF0Z tt` SPE)CTIOX. E COL Ffj"t}#PMENT J.?AiC`'€.MMY 140T
�'PdCl.'Q:4E'11ta'�.
PIDOL ANDIC-M SPA 1310001r, LZ
1f,45TIkDKO WSq.0 OF CO- AR SC 10H
13,wom
PLAN C:'Y.IFT FEE 101-000.439-.33..8 $93,64
C°CtSTRUCTrpT FEE 101-00.0.1418_ S1,44.04
MWHAXIC n , FRE -- FOOL 10.1.000.121.010 m.24.00
'
PLUMMY0 "T, MAI '101-000419-000 00
MA3 2001 .: 'FIVIRMC ', S :DUE NOW
$=3M
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
-Z—
INSPECTOR
�s- -•
• .o
�l�
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
'
Forms & Footings
Ducts
Set Backs
Footings
Slab Grade
Return Air
Approval to Cover
Steel
Combustion Air
Plumbing Final
Roof Deck
Exhaust Fans
Equipment Enclosure
O.K. to Wrap
F.A.U.
O.K for Finish Plaster
Framing
Compressor
Pool Cover
Encapsulation
Insulation
Vents
Gas Piping
Fireplace P.L.
Grills
Gas Test
Fireplace T.O.
Fans & Controls
Appliances
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Final
Utility Notice (Gas)
Drywall - Int. Lath
Temp. Power Pole
Final
BLOCKWALL APPROVALS
POOLS - SS
steel
Set Backs
Footings
Electric Bond
Main Drain (� d
Bond Beam
Approval to Cover
Fnuinmant I neratinn
Final
PLUMBING APPROVALS
Underground Electric
-
Underground Pibg. Test /
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
41j_1
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
Encapsulation
_ _
0`Z
X—tg—
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)