0003-291 (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
Professiortals Code, and my License is in full force and effect.
License # Lic. Class Exp.. Date
5744-2 i f/ ti tfik i1l1t'N
Date•✓✓. " ^.y, 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).
( ) 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 spec on'heed not be completed if the permit valuation isFfforff$t100 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' compensation provisions of Section 3700 of the Labor
Code,.l shall forthwith comply with those: provisions
�,. ., �>
Date: J.!_') �''-;,-;r='Applicarit,--~--""'/ r' �
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 •r!
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety s
for a permit subject to .the conditions and restrictions set forth on hist'.
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 cancellationA
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'ins ection,purposes.
Signature (Owner/Agent) ,I�Date-
BUILDING PERMIT �){J PERMIT#
9jidDfl�-�i9�
TE VALUATION oT TRACT
JOB SITE U
ADDRESS 35-444
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER.
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/ WI.Itt„UUN IKY ?.LUH UK., 6U111t e4
SAN UEkNARDINO CA 92403
PALM DESERT CA 92260
(760340-1032 Cka.L# 1044
USE OF PERMIT
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r�af A�fi-1�f�1i � A
k't'Oi...1 SPA ON Y -AL ARMS)BARRfER S SHALL T11 W PLACE AT
PRE-PLA,STM INSPECTION
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VALUATION 18,900.00 LS
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ENT f-41TC.1) C(NOIT 0 f CONST I U I C171 ONI
f�¢Ski0.fl1F
Plw.l(•tM1T FEF, SUAIMARY
PLAN CHECK ME 1011-ii0t1.439-318
C014,5TRUCTION FEE 101-000-418-000 4198.Of!
iLfFX11.ANICAL FF E -- POS:. 101400421-000 �23,tt0
1; X—CIIiICAL FEE— X000 101-000-420-000 S43.tk3
PLUMBING I-` iE, -- POOL tbi.000.,11.9-000 52111.00
®. ASD
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OR % 9 2000 ,
ZS$(13�i�T11,L CONSTRUCTION AND PLAN 0111 ECK
5422.70
1.1.5.5 PRE -PAID 1n1zt:;�
50.00
i t. TO1fAI, PERMIT 1iiTEM DUTNGVY
542.2.70
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RECEIPT
DATE
BY �') T
DATE FYIALE
INSPECT
./•e:
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
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
D 3
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)
COMMENTS:
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LANDSCAPE AND FURNITURE
92260 TEWCUA CA.
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APPROVED--
THE: SITE FOR. • A SCMUM.
FOR CONSTRUCTION
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