0203-206 (AR)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 Exp. Date
11001917 k3 MC`
Date Signature of Contractor
12011V
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 r.... 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
Stion 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:.
Carrier SfAT1'N' �U-ND Policy No. WC411410849
(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 provisions of Section 3700 of the Labor
Cone, I'shall forthwith comply with those provisions.
:Date: Applicant,km ..
; .. r.
—Aarning: 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
Tof 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 issuedas 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 1.80 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,- State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) '•,-1 Date L"%';
BUILDING PERMIT PERMIT# 10
DATE VALUATION LOT ' ' TRACT
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. Ma .. 1��.. �.*^�'� 1ihc75ldi►a'4p�„'M ,i.°r"t7 , �,6a�'n`i h'..,J
/.
JOB SITE
ADDRESS
APN
«t�- e�R��i�7 L� I � c1i►7
775401-04b
OWNER
CONTRACTOR/DESIGNER/ENGINEER
HAL LUMM4
t " d YNC .
LA QUbITA, CA 92253
PALM SPRU40S CIA 921262
(76Q)3Z3-0220 C^"f�:ta!>f 1620
USE OF PERMIT
.R STF.✓r!N'1' €LADIJrTION
65 57AVD!''.!'ION-'Z''ffA.S'TBR CWSTtT. 110A A'PP SENA L C:OiIFIR OD.
C•E,1VOM CONS'I'R33CTION 63,QA of
ES'Y7irt,IAT CC�LM.0 OF CC;.Y+7'S"X'RUC'nOR
5,oc ,sso
FLAN CHECK FUl 101 -000A 39^31 S $62,24
CONSTRUCTION FET 101 -OW -416-000 $81.00
ELS iTUCAL FEE 28
S"TRi1Tr1;3 tif;Tf01r M—F - I=fD 101 -WO -241-0004
FMAY i o iml,
CITYOFLAQUIMTA
FIRANCEDEPT .
[FFS-� C)1l►i. Ctrl i'I' tI7C:'#:1�41 'D1
61.03
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R ' ? 3 PRH-;IFA1D-1TXS
$0.00
TW
RECEIPT -
DATE ': ,
BY
DATE FI LE
INSPECTOR
o
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
22 oZ
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
0 7
Drywall - Int. Lath
Final
Final
8 Z
POOLS - SPAS
BLOCKWAL
A PROVALS
Steel
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
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)