9610-083 (RPL)y
L CENSED CONTRACTOR DECLARATION'
I hereby affirm under penalty of that I am licensed under of
BUILDING PERMIT PERMIT# CONTROL#
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perjury provisions
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Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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DATE � VALUATION LOT TRACT L
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Professionals Code, and my License is in full force anc effect.
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License # Lic. Class Exp. Date
JOB SITE � �
ADDRESS 79-615 TOM ZrlalO LN Iii
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OWNER
CONTRACTOR /DESIGNER /ENGINEER
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ate //2->S Signature of Contractor
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OWNER -BUILDER DECLARATION
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1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
79-61-5 TOM iKtWO LN N
4191..0 BOARDWALK #A2
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License Law for the following reason:
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PALM 13135%K Y CA 42260
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( ) 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
USE of PERMIT
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'ii•
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Code).
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O I am exempt under Section , B&P.C. for this reason
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Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
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() 1 have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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(�) I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. workers' compensation carrier policy no. are:
,It zCarrier
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STATE FUN17 Policy No. lt1t�-'1f:-tttkxr3 '
ESTIMATED C'OS 0 4:()iyf:i3•�t�.la.; M.lON
30.00.00ao
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(This section need not be completed if the permit valuation is for $100.00 or less).
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O I certify that in the performance of the work for which this'permit is issued,
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I shall not employ any person in any manner so as to become subject to the
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workers' compensation laws of California, and agree that if I should become
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A' its-31ANICAL flf-,E -- Ptic:►f, il�l-t)Ei )411-000
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subject to the workers' compensation �provisions of�Section 3700 of the Labor
Code, I shall forthwith comply with th seyprovls��.
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Date: %/ , ? Z -V Applicant-
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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
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addition to the cost of 'compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
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IMPORTANT Application is hereby made to the Director of Building and Safety
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for a permit subject to the conditions and restrictions set forth on his
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application.
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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 to4C
TAt, i C1Nt'.t;.ljf: !9C)Iti AND}'1./1.)"J 1�itl:c'i�.
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any permit issued as a result of this applicaton agrees to, & shall, indemnify
f.r;.t; PRE -PAID F'.E;ES
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& 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
• '1'tl'FAI, (1jt;j�jyj IT !i`KEN 9V NOW
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permit, or cessation of work for 180/days will subject permit to cancellation.
I certify that I have read this applieatZ and state that the above information is
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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
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the above-mentioned property forlinspection purposes.
Signature (Owner/Agent! Date
RECEIPT
DATE
/
BY/
DATE FINALED
INSPECTOR
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 Well Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg: 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
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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)