9908-215 (RPL)LICENSED CONTRACTOR DECLARATION.
'11 -hereby affirm under penalty of perjury that I am licensed under provisions of
Ghapter 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 ,0 to
s
r t'
YDate , gnature of Contactor f
OWNER -BUILDER DECLARATION `
I hereby affirm under penalty of perjury that 1 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 this
permit is issued. My workers'' compensation insurance carrier & policy -.no. are:
Carrier Policy No.
31 .101
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the workJor which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workeKs' compensation laws of Capomla`, and agree�thal if I should become
subject to the workers' compen sat'lonpovisions of ,S,ec on 3700'of the Labor
Crider sh 'ford with comply with. thpse provisions
Applicant
Warning: Failur&-to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines tip 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 Statelawsrelating to the building
construction, and herebyauthorize crepresentatives�of this City to enter upon
the/above-mentioned prope fo ;in' spectl n purposes.
SSignature (Owner/"Agent) i " " 7 `� Date
,<
BUILDING PERMIT PERMT�}�
DATE VALUATION���•: LOT TRACT
ADDRESS ,50•420', PVGjL j1u5S HILL .'ORM11
OWNER
CONTRACTOR / DESIGNER / ENGINEER
t" ir�p1 5G: `f 3J S.rw
r.kil *, ey iSrN1:rr�.s„
,.y+y Ar Gy q¢}
f.N Ii�a'R.'W.`� I
q`� t yl1,IgA ��{p�����y.• 11; ♦y �+�,1 ,I
l�I E. "J,Y0. Y.U�G6Ar� � V 1)R 1, Y
L"I QU€N`rA. CA 922,53
PHUSNINX AZ 85034
USE OF PERMIT
[�Cj�S�r 'TSE Ai.oULIIViW3flRIRMR 31WL 06 i'7•Z ATiVX,�•PLAXTM
MOL AN;LVOR. &P.r'o. 10,0U10 010 L S
xv�+�tnt,ua
PERMIT FEESUMM.Ald"
YALAIt4 C9.9F'CK FEE
CON'S t'R.1 IFY) I FF -P l t? 1 •fli Q Tt••9 a 17,(10
M%:<11AiitxCAL FEF -- POOL 1010.-W-421 -MY $211M '
I'lu [°RIC:..Ai klal -- P1uV+L 10,I e O06-420-000 $43,W
PL1JMf41NQFEE •,-.POOL 101-000-09-000
Sl.WMI_AT, C0N,,"'I'.R.1.Y7MK)N AINeDyy++3'i�.�yy,N C3. RCiX�
• Rai.'�W' �4 1-b�-4'3"1',.L f.J d- A)
$0.00
'3
�h"`fin/�"h'•
'
RECEIPT
BY '
DATE FINALED
INSPECTOR 'l
7�T�
r ��
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
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 Hacks
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
- G�
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)