9604-022 (RPL)H
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_ LICENSED CONTRACTOR DECLARATION '
-1 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 Signature of Contractor
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).
(-v,)'` 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 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. '
(This section need not be completed if the permit valuation is for $100.00 or less):
(',)"l -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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
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 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.
certify that I have read this application and state that the above information is
` `•j•rea'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 purposes.
Signature (Owner/Agent) Date
PERMIT# 1 CONTROL#
BUILDING PERMIT ��>4-�►zz 3066'
DATE 4/ �y% . VALUATION $9,147.45 LOT- TRACT
• i
JOB SITE
ADDRESS 51-77S ftV NIDA C OR FE.Z.
APN 773,151-043
OWNER
CONTRACTOR/DESIGNER/ENGINEER
rAP,L L" & J2ANN,E RQ,YS
C) Q11 .:/1111JILL.ER - SUBL14'T A'1 IAC:. ii
517,75.A.VENIDA C01612
IZ 010CA 922101
CATs'
USE OF PERMIT
POOL i1}aNOK SM
F'rJOL N SIOL' YARD L. F, 0 17' Y ffIi1fI
OAltl?I+N .BLOCK WALL L
I.1001, ANDJOR VIA tS,ililt).tl!) 1.8
5 FT. WALL
ENTIMAi i. TED C OST O t±'t3?� S r`:i`iO
r,14`7.�#�
ft,RMIT FEE SUMMARY
1>I,�trT C;i�4t:.C�• I'1?#; 10l�I1�JU-B'2�-�)f! - $�S;aC
I e"_ . =1
PVii;I�IAIrlCti9.il3i? "i°i)C?L iG�.•�(�i"IK!?Q u':G.,'f(t
EM1. luc;.AL Tl: — POOL illi -000420.000
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PLt1ii�T13trtC;•F`}��.4't:icJ(., : .131-Ul�r�l�-UU#) �z7.C►i►
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CONST111 r1_13 ! F11 -U . l- ( R_oo()
�
C"t i�3S'l'iiL`t�XLON ANT)I? A?�i (,*1HEt;h
$277.35
LESS P.RE-rM is
$0.00
`rqm , PC' -RN11T :.1w! S 1111 ?.:.NoJw
.$277,35
RECEIPTDATE
BY
DATE FINALED
INSPECTOR
IYFras.
i
INSPECTION RECORD
OPERATION
DATE-
INSPECTOR
OPERATION
DATE
INSPECTOR
' BUILDING APPROVALS
i MECHANICAL APPROVALS
'
Set Backs
Underground Ducts
Forms & Foogngs
Ducts I
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U. I
Framing
Compressor `
Insulation
Vents 4
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines.
Party Wall Firewall
I
Exterior Lath
I
Drywall - Int. Lath
i
1
Final
Final
I POOLS - SPAS
BLOCKWALL APPROVALS
Steel f
Set Backs
Electric Bond I
Footings
Main Drain I'
Bogd Beam
Approval to Cover
s
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping j
PLUMBING APPROVALS
Gas Test t
Electric Final I
Waste Lines
Heater Final I
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover I
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
i
Final I
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)
%_ 1 1 Y %--P Ir LH %—#lJ 114*A'H
' Contractor Address
Owndr
Job Address5177S 0gi (Q�CJ P
This form shall be posted on the job with the Building Inspection Card at all times
conspicuous place. It is the responsibility of the General Contractor or the Owner/Buil
to monitor the sub -contractors that are do this list are the same persons performing
work. Any changes of this list must be approved by the City of La Quinta Department
y Building and Safety prior to work being performed by a changed sub -contractor. Failure
comply will result in a stoppage of work and/or the voidance of building permit.
M
O
TRADE
SUB -CONTRACTOR NAME
CONTRACTOR'S
LICENSE NO.
WORKMAN COMP.
ON F/ILLEE
CITY BUSINESS
LICENSE NO.
GRADE/
EXCAVATEA�
//��2
C7
/NO.
aoS
HVAC McCH
Q
ELECTRICAL
ROOFING
SHEET METAL
FLOORS
GLASS/
GLAZING
INSULATION
SEWAGE DISP-
PAINTING/
DECORATING
TILE
CABINETS/
INSTALLATION
ORNAMENTAL
METAL
FENCES/
BLOCK WALLS
LANDSCAPING
OTHERS