9607-034 (RPL)' LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury'.that'I amilicensed 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 . It Cp. Date
� I2R Cid �a � iti;'31106--
Date Signature of Contractor
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).
O 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•foHow ing 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. "
()Q 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 i r ue/c,i,,Y, 6T Brkers' compensation insurance ca�rr�i-e ry�_P�oFrc�/r-no. are:
Carrier Policy. No.
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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�agreeythat. if I should become
subject to the workers' compensation �provi'sionsof Section 3700 of the Labor
Code, I shall forthwith comply with those provisions
�.r
Date: " fr' 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
fora 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 appli'cation and state that the above information is
correct. I agree to comply with alkity, and%State laws relating to the,building
construction, and hereby authorize representatives of this City to enter upon
A �;v
rop
the, above -me ntioned perty,for inrspection purposes.'
tiSignature (Owner/Agent) ,!.! Date '• '
BUILDINGPERMIT PERMIT#. CONTROL#
rY 1L�1
W"_ 034 3.695
DATE 4p VALUATION LOT • TRACT v
C� — � ..� ip
JOB SITE
APN
ADDRESSS -424 wWILI1tOWN 1ri.1Li.
�'.
OWNER
CONTRACTOR / DESIGNER / ENGINEER tii1
MR f51.,t3.DOIE'1`I' ° .. ,.:
C.AI,IRY"IT,A.P00.L.S &SPAS
55424 SOV11*1W HILLS'
41310 80AR DWAL.K M2
LA QX INTA
1'A1:,:M hk SER''1' CA 92260
(610.)3R1>-9UQt1 CIALO 355
USE OF PERMIT
P't.lt.lL A'N 1 �l01t -kit\
1'0k.).L Elis D (.:A -%Pr:. 1:1,0100.00 LS
'"riAtI`ED i..t' S C OF CONSTRUCTION
�.I��a1�I�r 1� f�:,1i„SL►lYI11+�A!-LY :...
PLAN CHECK FEE 161-00"39-313
MAJU3°6'ktJ w1' ON FEC' 101 -0004118 -ow'' $126.00
MECHANICAL FRE -_ K)0L 0.1-000.112:1.900 $24.0
r�LE("r.WCALFF ,._ P001. ►101-(u) 0 t►•i o0 $45.00
1 L;UMKN(11FT21E-,1?Oe.*L. .. 101 U1►n 4il'.=t1�u) �b'r,ao
X 13-TOTfAC. CONST' UC'.('ION ;AND KaIkN C1iECK
�SQ.31?1f
LESS .PRF-PP�i17 ��1 5
som
T« ', :AL gpERMI I•. I!'EFS DUE NOW.
RECEIPT
�j /, * .
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric IX
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
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 Wdlft ( eRn)