9706-068 (RPL)LICENSED CONTRACTOR DECLARATION
I:hereby affirm under penalty of perjury that I am licensed undea-provisions of
G~iapter'`8 (commencing with Section 7000) of Division 3 of the Business and
v;` ,< -
Professionals Code, and my License is in full force and effect..
License # Lic. Class p S. .xp. Date
� 3idr 1
Date- l Signature of Contractor—
OWNER-BUILDER
ontractor OWNER -BUILDER DECLARA ION '
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 theproject 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.
Se( ) I have and will maintain workers' compensation' insurance, as required_by
tion 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:
Cartier Policy No.,`
STATE Ram wl 8021
(This section need not be completed if the permit valuation is for $100.00 or less).
,th
() I certifyat in the performance of the work for;whichithis permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation.,laws of" California, and agr,;'ee7that f I should become
subject to th workers' comp cation provisions ofrSect on 3� 00 of the'Labor
,Code,�I ah II o��R�r� ith comply with thoseyprov cions. j
Date:�n�� +''r' Applicant
Warning: Failure t'o.secure Workers' Compensation coverage►is unlawful and
shall subject an employer -to. -criminal and civil fines u�i�4100,000, 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 permit to cancellation.
I certify that I have read this application andfstate that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby^authorize retpres natives of this City to enter upon
the above-mentioned property for iiispec`tiio' p�urplos s. y
Signature (Owner/Agent)
il Date lu - `
BUILDING PERMIT PERMIT# CONTROL#
BUILDING
1L�, 9706_0685328
DATE VALUATION LOT - TRACT
JOB SITE
ADDRESS 7"80 ►JUN-HROOK
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
S�it,A!����,.t t�lif:�i
A[vTEt�fi:1�iVt'tDOLC�'sJttS`i�:.l'.JG"C'9ON
78 -SM SON1113ROOK'
68575 ;ABY F LIPP, kD
LA( D1'fA CA 997,253
CATIVO.RALCRT CA, 922,1
(��it1)3ZJo t ,ty C13L4 1.1.04
USE OF PERMIT
POOL
L
# OCJL XKD : P. . ONLY
1'/00L AND/OR SPA. 15,040.06 1.3
it.SI'�S��ATE-0 CSS' O.ir+' CONSTRUCTION
15,06T.00
Vckm_i t RUP, IsiAMAii'rt
PT -AN C_ iHBCK FEF. 101.0010.439-31.8
0INSTRUC.11r...N MM, 101-000-M-000
'bfi l:ir\J3iC rl3,.Ft1 -r.' L" illi-fliltis �!-iii) $NA0
M fu't'W Mt hid#. --1'WL ' 101-4�A�'i4?"00 YA5.01)
3?LiJiLfl.4f NO F, 4; 17, ,P 0tJ3 101-000-419-000 =«7".fi!)
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St.T=C'f)TRI. C'ONISMUCrIONAND PIAN CH13C K.
4;M 30
LESS PRE-PAID.H.E8
$0.00
RECEIPT
DATE
BY
D=ED ED
INSPECTOR
INSPECTION RECORD
' OPERATION
DATE T
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
E ui
Underground Electric
Underground PI
Final
PLUMBING APPROVALSas
Test
anal ? /
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
CK for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
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)
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BUILDING. & SAFETY' DEPARTMENT
CONDITIONALLY'
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