9908-213 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty'of perjury that Iam 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
�� ism°!� ' "� �� ✓, 06/30/201
Aoe
off.
Date/—_ %' WSignatureof Contractof- "rte
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).
(
)'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.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance.of the work for which.ikis
permit is issued. -My workers' compensation insurance carrier & policy no. are:
Cartier q Policy No. (M�
(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
worke5 ompensation laws of California, -•and agree that,Y I should become
subject to the workers' compensation provis'loy�s`of Section 3700 of the Labor
Co/e' hgl1all fOrthwith'comply with�those p"ro sions.,r�
Pate: -4;� 7� ~ Applicant
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 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 authoriiie)represeritatives of this City to enter upon
the above-mentioned.property fo of spect on purposes.
,Signature (O.wner/Agent)!_ ~ DateF
BUILDING PERMIT PERMIT#
"48-213
DATE. / VALUATION LOT TRACT
ADDRJots SIESS ,.Y '3l0.`�' 1 �i:�i �A RILL DRIVE
APN 79'9-050.008
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Rfr flo"M FE 8 11C
rut IN
f O :63C,X 810
1425 R. Uig NTN "S1'TT ,IAIVE
LA (�Q�li[+ TA � C: t1.' 93253
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CHL# 49",
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USE OF PERMIT `
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RECEIPT
DATE
BY
D E FINAL DD
v_
INSPECTO
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test
Final 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
— �7
Gas Piping
Gas Test
Appliances
Final
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)