0110-028 (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 mi License is in full force and effect.
License # - . Lic. Class Exp. Date
Dat/`�.'S.��j? Signature of
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 BRP.C. for this reason
Date Signature of Owner
L
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.
'(;w" 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 issued. My workers' compensation insurance carrier & policy'no. are:
Carrier -VIASI PONAD. Policy No. 040.0100104.1117 -
(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
Code,).sh U fo v ith comply with those provjslo s. ,o» :P
Da t2: r r 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. s
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 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 buildirig .
construction, and hereby authorize representatives of this City to enter upon-. I
the above-mentioned property for inspgctiop purposes. +
� � ate
Signature (Owner/Ageritj"•�"��%F"
BUILDING PERMIT PERMIT# --
DATE VALUATION LOTS TRACT
't1
�7'�3�18P.� • . ' �,
JOB SITE
ADDRESS 51440 .,YMA VAU.100
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER -
.51 -140 N"141D1b,'i4. 4=70
Ro. DVA SI X91
TA. QL1XIA CA 92253,
LA QTJL MA CA 92253
('7601160.3585 CHIA - 045
USE OF PERMIT
1%091- AMOR SPS►.TW
v,
POCIUSPA, ALARM.-,/tEARRIEIR S1-fja I I., BE.IN 2Ti1,rRCFA'a PR,&P1. TER.
19OPFC11014, POOL. ItOUIPM t ECLOSUPX, PVO iPir.LUDL� .0, .
P001, ANTNOR SFA 7,040.00 l nl
MAN CHECK FLV 103. -000,439.31 R MIN
CONSTRUCTION It3VI2t 1 Q 1-+�-+ i 1 E3 't1�3 �4►O.iitb
MMIC �.�3�i1CAL. Rut -- POOL 101-000-421-000 S24,00
,t1XXrfR1CA.1,. FFZ - POOL. 101.000-'2.0-000 $45.00
PLUMBING M 101.04XI-0,9_000 $277,00
c1
gUB-71' SL%rI .0W AXD .P1 CW- M.
�►SM4.50
` LIM PER -P 1'?
$0,00
YW=r1VffS DUE NOW
$244,50
TO
RECEIPT::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
i Compressor
Insulation
Vents
Fireplace P.L.
s Grills
Fireplace T.O.
; Fans & Controls
Party Wall Insulation
I Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS '
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
�p
Bond Beam
Approval to Cover
•
Equipment Location
Underground Electric
Underground Plbg. Test
_?
Final
Gas Piping
/Q
PLUMBING APPROVALS
Gas TestElectric
Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral ti
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
66
Gas Test
Appliances
Final
COMMENTS:
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)