0208-125 (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 #Cs11 Lic.FCllass�sy �y Exp. Date
/dyh�
71
.%sf' .
Date Signature'of Contractor 14 J
_
-- P
OWNER -BUILDER DECLARATION
I hereby affirm underpenalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ,) 1, as owner `h\t� property, or my employees with wages as their sole
compensatior'i',* +ili ,11e work, and the structure is not intended or offered for
sale (Sec 7044; Business & Professionals Code).
( ) I,tias owner of i�Tp property, am -exclusively contracting with licensed
contractors to.,constri ct.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.
6� I-ha've 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 JTAi1 CO4&1 p,,N,9AT1,, Policy No. 0.160006133.01
(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' compensatio provisions of Section 37 0 of the Labor
Code, I sall'`forthwith comply wit, *those Prov' ions.
Date:, « Applicant /-,
Warning: Failure to secure Workers' Compensatiori 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 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 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 autho)zelrepresentatives of t 's City to enter upon
the above-mentioned property for idspection purpose .
Signature (Owner/Agent) Date
r
y
-- BUILDING PERMIT PERMIT II
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS ��( APN e
R
OWNER CONTRACTOR / DESIGNER / ENGINEER -
T0U MICAWM 1917 CKTZ ORNIA P001:.13 &, S AB CTOP WN C(7.
74.9231,10VEL YLAME.ASrMMW-220 ?4725J-01`iIDRAT, S"U=RA.
PALM DESERT C -A. 92264 PALMDESERT CA 922-160
(760)340-,90,00 OBLA 00-35-5
USE OF PERMIT
POCitMP4118Q F}I!EPIT, ,R LdUZl &ftAP.F,1r,, S1' A. LL BF. 1'N PLACZ
P'PJv4Y TO P±#&PIASITIR INISRECTlON,
P001: Ah DIO R SPA.
5 FT. W. MA. I 15.00 LF
E6M1ATXD COQ UP C011MVC ON 22.32 4.75
FkWal FRU lel`%0"RV
1'I.AN CHWK M_ 101-.000-433.318 $152.14
CONSTRUCTICYN ME 101-000.41 "00 $134.00
IfAZI HANICAL PER -- POOL 101-000421-000 324.00
SL,=TRJ 4X. FW, «- POOL 101-000-420-0,00 20.0,00 W.W
'I'?LiD IDIWO Mei - POOL • 101-000.419.000 527,00
T)Aa :CAS C k< C tVal (014 AN PLAN CHECK
Ims FRE -PAID IMU."S. 00
AI10 0 6 7UU1;'
it 'VE€l" fi
IMS DUE .A4D <.
WYOFLAQUINTA
FINANCEDEPT.
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RECEIPT DATE BY` DATE FfNALO INcfE R
:L
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
POOLS -
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
Sewer Connection
Pool Cover _
Encapsulation � .
Gas Piping
Gas Test
Appliances
Final 4
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: