9908-083 (RPL)LICENSED CONTRACTOR DECLARATION
16�?by affirm under penalty of perjury that I am licensed under provisions of
s0hapter 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
-�,racCr°
/ate -- .
gnat,
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).
O 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:;
( 1 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`
Cartier. Policy No.
STATE r '
ti 3.5+ .1z3f!
(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 ��6t employ any person in any manner so as to become subject to the
work fs' compensation laws of Ca if and agree that I should become
subject to the workers' compen atlon provis bnns'of Section 3700 of the Labor
a6de, I shall'forthwith comply with'those pfovlsions•.- 7 ' ` `
-6ate: `-'`Z_ �`�Applicant f�\ a✓ ✓ ._ `
Warning: Failure to secure Workers' Compensation coverage, is. unlawful and,
shall subject an"employer to criminal penalties and civil fines up to $100,000; in
addition to the cost of compensation, damages as provided -for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT. Application is hereby.made to the Director -of Building, and Safety
for a. permit'' subject to the" conditions .,and' restrictions set forth on his
application.
1. Each person upon whose behalf this application is made.& each.person at
Whose request and for whose benefit work is.performed under or pursuant to
any permit issued as:a result of this applicaton agrees to, & shall, indemnify
&.hold harmless the. City of La Quinta,.its officers, agents, and employees.
','2. Any permit issued as'a resulUof this application becomes null and void if
work• is not commenced within 180 days from date of issuance .of .such
permit, or, cessation of work for 180 days will subject permit to'cancellation.
I certify that I have read this application and state that the above information is
correct. .) agree to comply with;.all. City, and State laws relating to the building
co struction, and heretiy authorize representatives of this City to enter 'upon
e above-mentioned property �for inspection purposes.
Signature (Owner/Agent) �'w �'"- Date .X "'
- BUILDING PERMIT PERMIT3�
DATE 1 VALUATION LOT' LOT TRACT
JOB SITE 79-405 ''�;�C�i JA
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
3�O 13 glti ':
1u5 E: �3AdY'W'>t,.S.aCY 11121E
1A QTANT11 CA 92253
1r'HOEMIX AZ M34
USE OF PERMIT
POC3L A.1> D11DIR SPA
POUL & SPA ()NLY - ALARMS13ARRJE .S SHALL BE Iii PLACE K
PPM,PLAS'TER 9NSP.Wf3ON
B 0rX ANDQR SPA 1.O,flUf3,F3i7 .�.�
•
I�:��:A'I119[�;A �:� •CB's' �� G;d9.i�;��'.$�.I1�'�•�da:�V
A
�9i,.R�til.�ii�
ERMIT FEE SMIMARY .:.. .
PLRN C,WCk 'F X 101-4)00-439-318 $76.03
COINSTRUC7'ION F'E'E 101-00041&,000
42 C'1'3Ai+itGgd. FF_E . Pt,�n1 1 31 'f it-ei(+Q $24.,00
EC"1 t�TC;A1 0004W-dRO
PLUMBING. F&I -_ POOL 101-600-4 D 9-wo 3277100
3i7B•"1MALl CONS"AM C'`&'I0ND.F:.1..NY CHECK
V289.05
3'rS4;Fids=PA D FEES,
RECEIPT
DATE
BYEDATE
FINALED
INSPECTOR
INSPECTION RECORD.
I 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
0. 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
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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 z.
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
�� U
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)