0104-248 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Nf =• Ch.1pter 9 (commencing with Section 7000) of Division 3 of the Business and
CU) Professionals Code, and my License is in full force and effect.
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= M License # Lic. Class Exp. Date
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893-ILI tt �3 0
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tih CD OWNER -BUILDER DECLARATION
Wa I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
cr) () I am exempt under Section , B&P.C. for this reason
NDate Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
Z
I hereby affirm under penalty of perjury one of the following declarations:
A 0 ( ) I have and will maintain a certificate of consent to self -insure for workers'
K W ILL compensation, as provided for by Section 3700 of the Labor Code, for the
J Q performance of the work for. which this permit is issued.
n Q O ( ) I have and will maintain workers' compensation insurance, as required by
j C) QSection 3700 of the Labor Code, for the performance of the work for which this
L LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
ao. _ STA.'1'9 RMI) 140000202197 No. (4t 000202197
�CY
J (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'[ should become.
subject to the workers" compensation provisi9pss of Section. 370,QRfthe Labor
Code, I shall forthwith comply with tho �C+�Qris. ,G
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 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 benefitwork 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 epresentatives of this City to enter upon
the above-mentioned property for s ction p ose
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT"
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS
OWNER CONTRACTOR /DESIGNER / ENGINEER
LtiiLAWEtW.ANIlOk h'Bl.AL[I-XiS1' C
'16995 :[x[:OYMMAY:LiM9
PALM 171MRT CA 92211
USE OF PERMIT
T'vUL AWD/OR 12PA
AIX AviIT RICAN idC1N0, B R LLrFAS 19C
739i F'LO. WLIA A. ITE
1M,1.and':l:Y8wFAT (Vk 92211
C;60)200�0277 0B14 637'5
P001, Ori LY - A AR.M..;fBAI'ZRfi RS MUST I% IN f %AkC% AT
WNI PION
POOL AT' WOR OPA
0" 100 14
MF::CislA7d CAL RIE __ POOL 101-000-421 . OUO SA"14100
ELAT..CTRIC°AL FEE -- POCYL 1011-00(" 20-000 $45.00
>PI.T3MitT O FeF, _ POOL, 101-000-419-000 S217.00
CONSTRUCTION FES 101 -OW -418-000 $QO8.00
R[3 '.iCY)v,1 CO1`iKRUC:"1•'tk' N AND.MAM i."'HUX.
IMS FRF,-'A1D FE.tt0
APR 2 0
TY OF LA QUIN
FINANCE DEPT
",W)AM
S2flA XY3
$0,00
'1 O A , .i ERAlTt'Y''1?°C'ES TD'ATJ.I 14OW �d�,ti41
RECEIPT DATEE BY DATE FINALED INSPECTOR �s
USP CTM RECORD
,. OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
HULD® NG APPROVALS
R4dECHAN5CAL 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
SLOCK"'VALL APPROVALS
Set Backs
Steel
Electric Bond
_
7
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUHB�NG APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Tap Out
_
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
EncapsulationGas
i
Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECT=AL 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)