0211-178 (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 ;S J,Exp. Date
of Contractor
OWNER -BUILDER
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).
( ) Lam 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 iccuo!t My workers' compensation insurance carrier & policy no. are:
Carrier STATE FUND Policy No. 431) 7gft-9i►
(This section need not be completed if the permit valuation is fopf$100.00 or less).
( )' I certify that in the performance of the work for whirl) t is permit is issued,
I shall not employ any person in any maPner so as to bye ome subject to the
workers'fhaiii6GR
compensation laws of Califolnia, and agree tat if I should become
subject, the Avorkers'�ompensation rooyl�sions. `S ct'on 37 0�tof the Labor
Cod6;t comply with tho_ e1rgyisiojis. 2171 A J3 ;A
WaihThg: 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 alto ney's fees. R
IMPORTANT Application is here / y made to the Director of Building and Safety
for a permit subject to the conditions and 'restrictions set forth on phis
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 l have read this application and state tha),the above information is }
correct.I agree to'comply with all�Clty, and State laws relating to the building! "
construction, and hereby authorize reApresentativ"etof this City to ente upon
the above-mentioned property for.lnspectiio�n 77/v rpges
Signature (Owner/Agent) 1 �1 Date
a 6
BUILDING PERMIT PERMIT#
/ Q%11-178
LOT :,p TRACT
DAT& } / VALUATION �
JOB SITE
ADDRESS .T►� i $ y l it C��x.7
APN 714-0.14-W4
OWNER
CONTRACTOR/DESIGNER/EN (NEER
ploe BOX 3578
45-260PA11MV,
(160)347k0500 t:HLO 4998
USE OF PERMIT
X)OL MINOR VA
s2COLISI9A.sf3iWy.StAi_R1i"WALE, fi3}rCX A`P.21Z*P1,A
•EF,
qXrpUDD,'
SPEEn3`KipOU8rfRK WCLOMOIRUNOT
:s
.P=,,.Pe'i,:DJOR SPA
£"E.M ' SiT"aSUMMARY
1R 00 39-c1` $76 !05
PLAN Q11A;K F72 301-000-439-318
CON!_aT&1LXCTiN N*101-000-410-0000 g117.0,11
FEE -- P001, 101.000-421 000 MOO
9UMfCAL PKE,.,, POOL if^s-•000-420.000 $45.(tt1
PLUA9BINO FRE -- POOL 101-000-419-.000 $77.00
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F,yY' p_'i i. mitu(,,,.-JOMAA rig %.grafi .0 s
2>s3�.ifs
MAR 14 200' 0 VC�t11 YXE181 o F.IgI aw
CITY OF LA QUINTA .
FINANCE DEPT.
ECOPT
1)
I DATE / ,9 t
l f70r :
BY--.e.....M -
DATy,FINA ,�
(Ll
INSPECT
INSPECTION RECORD
OPERATION
DATE
I.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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS = SPAS
BLOCKWALL APPROVALS
Steel
��b�C3
Set Backs
Electric Bond
Footings
Main Drain
B&A Beam
Approval to Cover
Equipment Location
Underground Electric
33- , 2 v7. _
Underground Plbg. Test
Final
Gas Piping
'p,` PLUMBING APPROVALS
Gas Test
Electric Final
Waste ines
Heater Final
Water wiping
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
rxlerground Conduit
kou-h Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
:KV
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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