0012-075 (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.' Exp. Date
787503 B Ziac---�
Date-! s*��� ` Signature of Contractor h�
OWNER -BUILDER DECLARATION..
I hereby affirm under penalty of perjury that I:am exempt from fhie"Con actor's
License Law for the following reason:, t' )
( ) 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 & Professionais.Code).
as owner of the property, am:exclusively contracting with licensed
contractors' to -construct" the project (Sec. 7044,• Business & Professionals
Code). I .
() 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:
O 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..
( ) l 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..
00
(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 I should become
subject to the workers' compensation provisions of Section. 3700 of the Labor
Code, I s,.hajl forthwith comp,wit those provisions.
Date: D.1mirw Applicant rdr" =` •i 1� 3'. !.
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 Setforth 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 issua,nce.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 representatives of this City to enter upon
the above- mentioned-proppeftyy,for inspection purposes.
Signature (Own•- r q,' %1 Dat
er/Agent)e
i.. IIF I n K-
',; BUILDING PERMIT PERMIT#
DATE y VALUATION LOTTRACT.
WRTl
JOB SITE
ADDRESS
APN
78-- AWNIVAUNCtI,
OWNER WF
CONTRACTOR / DESIGNER /ENGINEER
Lama CO.@ 49DI. INU ° . ; . VIOES .
.P 0 *Boy. 140
P,O. BOX 937
1+.A, Q:0WrA CA 92253
%fie QYMgTA' CA 92253 .
E:'91'a .
,
USE OF PERMIT
PCOM AMOR SP
SUPPLIEMWTA L TO ,<?l RMIT9at;?-W WWWANO a lb- MOLE OF
CON'PdiACTOIL.
HowwNwo COST OF OONVI MM ON
6 �p
PERMT 1W SUAO&ARY
101 -WO -423-000 84,30
1.
MM-Tt OTAL, PONW—R JC1-1014 AND PLM CHWX
94.50
W PRE-PAi1J E -EES
$0.00
rOTAL FER.M. I Is DUE ROW
44,50,
DEC I.�.2� ..:
RECEIPTDl�E��
BY
DATE NALE
INSPECTOR
f
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 f
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
BLOCKWALL APPROVALS
Steel
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures I
Main Service i
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp: Use of Power
Final
Utility Notice (Perm)