0404-019 (RPL)LICENSED CONTRACTOR DECLARATION �.
I hereby affirm under penalty of perjury that I am 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 ExDat
P� ;t�f,3r`ii�
•Date-- Signature of Contra or
OWNER -BUILDER DECLARATION 4i,
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 hav_e_and will maintain workers' compensation insurance, as required by
Sectio 3700 of the Labor Code, for the performance of the work for Which this
permit isjiissupid.Gyw�orer�sclo�npensation insurance javrs�lilpa:;Fy! no. are:
Carrier Policy No.
(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
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation p ovsions,of section .3700of the Labor
Code,l'sh'all forthwith comply with thor a P�rovis oris. r �
Date:G%' Applicant s%f'°r•1 ,? •�
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.
mployees: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 authorizeepresentatives of this City to enter upon
the above-mentioned property for inspection purposes.,
.Signature (Owner/Agent) ��''- � Date/
;A
BUILDING PERMIT PE"I0T 04-019
r
DATE "� + ! VALUATION g -424.75 LOT 1034 TRACT
JOB SITE T s Iii B..E�:. Uti Ba�fY;
APN - -
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
•
& WF.0dA9
CAi.sti OR'3ti17.A.F'tJOLS & aSTIA CI -OP MAN C01
81.260 AVEMJi 62
�f t-100 AMME 54
LAQUDITA CA 92843
COACIUV A CA 92236
(1760)398-9222 (MIA 0036
USE 0,
!MI -11 AMr)qPA Ilan AIJ4,'l!F.11,3 .,i 0010 :.R r? I HSI
I A VV V Tliflf'VIVA I!
CITY BUD. ALA:Rh&SAR VERS Si` ALL .BE R4 PLACP I'ItIOR To
PREPLASTER INSPECTION.
POOL ANDI RSP.A AMA U11
3 Fr. WAL€. 13. W LF
E5'I'.[11 MAXED COSH' O:f.+' CC.1MMl7C',I 014
18,324.:75
PLAN CHECK 1EF, 1€�1 •GC3t� 439<31 S $120, I'0
CONSTRUCTION PEE 101-060-41 S-000
MECHANICAL PRE --• POOL 101-000-421-000 5324.00
ELF,CTRICAL "M— POOL 101-OGIO-420-000 $4`1.00
PLUMB 13-40 FEE -- POOL 101.000.419.000
81dE'WrAL 0* 1V ilAJ.'.UCT1014 AND FILA.Cq CCLf:.CE'.
$422.10
LES 7'IF-nK'1TU �33
$0,00
'1'MAL "
$422,70
.PLMITT r) i� VVE NOW
RECEIPT
DATE-'Jl, , i jk
"j V,
IRD
BY fes `
DAT FIALED
INSP
i :
5
W.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
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
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
Set Backs
Steel
Electric Bond
POOLS - SPAS
Z
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
10, PLUMBING
Gas Test
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
7�
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
v