9609-126 (RPL)LICENSED CONTRACTOR DECLARATION
I hereb/9ff((irrrmmencing
under penalty of perjury that I am licensed under provisions of
Chapt with Section 7000) of Division 3 of the Business and
Profegsionals Code, and my License is in full force and effect.
cense # Lic. Class Exp. Date
�y6, /77
Date �, /� `9 1Signature of Contractor -✓ �f %'
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 .tbe .Labor Code, for the performance of the work, for which this
1i�1� ��J1�1[i Ati!h1il9i
permit is'Issued. y workers' compensation insurance career & policy no. are:
Carrier % Policy No.
(This s./c tion need not be completed if the permit valuation is for $100.00 or less).
() Vcerlify 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
wo ers' compensation laws of California, and agree that if I should become
ject to the workers' compensat�io .provjsions of Section 3 00',of the Labor
de,&S ith comply wit lhI se,,prov sions. _t
ate: w. Applicant 't,,..,
Warning: Failure to secure Workers' Compensation eon erage is unlawful and
shall subject an employer to criminal penalties -and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2.�Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such '
erm it, or cessation of work for 180 days will subject permit to cancellation.
I ertify that I have read this application and state that the above information is
orrect. I agree to comply with all City, and State laws relating to the building
onstruction, and hereby authorize representatives ofthis City to enter upon
the above-mentioned prop„elty for inspection purposes:
Signature (Owner/Agent) -Date % L
T#
BUILDING PERMIT PERMICONTROL#
OL#
► -�� 0.7
DATE VALUATION S111,0".60 LOT TRACT
JOB SITE75-775 SPYGLASS MLL 1)R
APN
ADDRESS
-OWNER
CONTRACTOR / DESIGNER / ENGINEER
S+"1'1f .1,fi,"L7..ARIN1
i'NM1 PIUSES
SAME...
2"70,AV.8, PIt NU&VER.
1.,a1 Q ..IWA
t,'-w"Fu:l3Tt.Ai. cay CA 92234
325-21147
ff+iil)32S•21.fi % C1,,f1 1Kt2
USE OF PERMIT
I' XA, AN1.YOR SPA
PCA -4. ANI) SPA.ONtt1 Y
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LSTI NOIXUD CONT OF C ONO S°,c'ItUCTIONy
11,tM�ii f.00
+t'ERAlIT VE.E. SVAljilA RV
MAN E. ORCK Cw. 101-01*449-' S81.90
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CONSTRUC71QN11=7111 tot -M -41.$ -UOQ 5126.00
MECHANICAL ANICAL 046 -- KDOL 101 _OW421-OW SZ1.00
eco
CLI I'R(C>'AL 1-4-11-- iil YN, 101 -OW -420-000 SA S.EN}
C
Pt.t74 IiNi1 KTP001. 101 -OW -41 9. O $27.00
;
l LLLJ
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S! 13.7WAL CONSTRUCTIONAND PLAN CHECK
$303,90
1 -*SS PRIi.-PA10 V_RES
$().()0
TOTAL PERMIT FERS DV NOW
S.3(l3.90 ..
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
steel
POOLS - SPAS
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
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:
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