9709-126 (RPL)LICENSED CONTRACTOR DECLARATION
I herebyaffirm under penalty of perjury that I am licensed under provisions of
Imo- Chapter 9 (commencing with Section 7000) of DivisioW3 of the Business and
N W Professionals Code, and my License is in full force and/effect.
License # Lic. Class Exp. Date
CY 650128 c:5 NM/97
IZ
oZ r-- /Date . y,Signature of Contractor
co O.
J U C:) OWNER -BUILDER DECLARATION
HWW r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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). ,
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
00)
d WORKER'S COMPENSATION DECLARATION
C) < � 1 hereby affirm under penalty of perjury one of the following declarations:
Lo H O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X Lu �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CD Q U ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
li rn F— permit is issued. My workers' compensation insurance carrier & policy no. are:
z CartierPolicy No.
r -p
J
(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 #nner so as to become subject to the
workers' compensation laws of Califofria, and agree that if I should become
siu'7bject to the workers' compensatiof provisions -of Section 3700 of the Labor
Code, J1�shall fortthv�ith comply with tho e' provisions.
Date: •'fib / 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 iof 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
cTstruction, and hereby authd;rizeirepresentatives of this City to enter upon
t e above-mentioned property,fol n spection purposes.
Signature (Owner/Agent)���f
Date
PERMIT JI
BUILDING PERMIT `'�''�"�
°°NTR°`#
5973
y�
DATE VALUATION P1;�*i7,,t}� LOT :s{i TRACT.'�''
117
JOB SITE 79-320 X I.O'NWA ,
APN
769-76"20
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
S.t QIA'K1'14. C�12CA 1,"U"M Pt�R VNt R,8
C:tt1,11't..31:"13r�s i't;�Jl.;:'�L�.
SPAS
41.533 COOK sr #26o
744123 Judi 1 R1VF, 0A
PALM CtEs i ft l' (,A 972.11
PA"'Al DESERT
('.'A 92 260
7f�(1'1:�:1Q•�+L1F?f1
C:13I,it 355
USE OF PERMIT
PCttwL. SP? W..ViEk FLATUiRk AK0 `tilia<1.
POOL AJNWQ_1� SPA L'i
PUMOT FE11a'Si3iUMARV ..
Pf .AN C14Jg1',`K_F'F1 101-r"439-318 I63 %41
00131111TR C,130N F15P. 11►1-fDf'A14Ik-f0) 12ti2 (it)
T%1 -- TOOL. 101-000421-000 SZi.&J
EL E( tTWC^t�1i, F"E#s--1�OOL 101 -OW -4,20-000 0 $45.00
<
i!(..L11IRT-Vt.7 FIZE,.. K011 101,-060-41940`11 S217,01)
D7
m )
Cn
CQ
J
CL a
LL.
-w
0
Cn
�F '-n.yl:r1,
S1! Rn
Qb
L.ESWit, lyl>U': fn F;•.'.t
.- . � c
TOTAL PEAMIT FEES Ot3E NOW
ra.5f 1,1111
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR...' '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing a
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 U— !I—
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
Fudures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
T np. Use of Power
FUM
Utility Notice (Perm)
COMMENTS: