9908-212 (RPL)' • :
LICENSED' CONTRACTOR DECLARATION
=1 hereby afflrn?, under penalty of perjury that I am licensed under provisions of
ter 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
/I 690V15
°,
jDat" a r°� Signature of Contract• r-=
:. 4.1 /.
- OWNER -BUILDER DECLARATION .'
I hereby affirm On 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).
as,own& of the •property, am excldsively contracting with licensed
contractors to construct the, project (Sec. 7044,: Business :& Professionals
Codej,
O I•am exempt under Section. B&P.C. for this reason "
Date.
Signature of Owner"'
WORKER'S COMPENSATIONbECLARATION"
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 'Cocle,,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:
Carrier Policy No. .
AW
(This section need not be. completed• if the permit valuation isfor'$100.00 or less):
O 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
worker compensation laws of California, and agree that if I should become
subject to the Workers' compensation provisions of Section 3700 of the Labor
Code, °4L -shall forthwi comply. wlih�hgse pr6visions:'"
C,Date: . i'el!APPIiEant
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, a result of this applicator agrees tq, & 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.cEinc6llation.`
I cert'ify.that I have read this application and state that the above inf6rmati'6wis
correct. I agree to comply with all City, and State' laws relating to the 'buildirig
construction, and hereby authorize representatives of this City to e6ter'upon'
the above-mentioned property for pspection purposes:,-
ASignature (Owner/Agent) �----�••_--•:Pate
PERMIT #.
BUILDING'PERMIT'rti�:F�
DATE,rr! J VALUATION.*a�+' LOTTRACT
el
JOB Sift 560
ADDRESS Y ���aL�WI1Qr ..�
APN n��7i@S3
`OWNER ,!
CONTRACTOR / DESIGNER / ENGINEER
RTr HOMES I,IX" -
K ;Efa,`x 810 :.
142 . tliv'kVF at. Y:1J1tI ,
E,A QUfW.t'A e.R. ^' 'fid
PHO-FRUe _', !4 85,034
(Ctf21 �7 t,tt� �1Z!8J1 P 4!M
USE OF PERMIT
POOH., ANTI/aP, SPA
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i
PW,. d'a14"DICIR 0111.1A 10,000.0011's .
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l V' S PRETf3:tll W.
•` 40,00
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RECEIPT
DATE
BY l
DAT FINALED
INSP TOR
INSPECTION RECORD
OPERATION 177_DATE
I
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 - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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
Gas Piping
Gas Test
Appliances _
Final
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: