0211-142 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I amlicensed 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. R.
License # ( Lic. Class t Exp. Date r
�
A -t, ,
.Date �* t_ Signature of Contractor ��-- , 1k t
OWNER -BUILDER
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 (Seca 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.
(1.;) 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 STATERSN6 Policy No. 229-92.06149334
(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 sous to become subject to the
workers' compensation laws of CaliforniaNrid agree, that if I should become
subject tdtthe Wworkers' compensation provisions 3700 of the Labor
Coale, l`shalllfoithwith comply with those-provlslons.
,,if te: '� Applicanf'— . I r -
Y \
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 hiA
application.
1. Each person upon whose behalf this application is made & each person of '
whose request and for whose benefit work is performed under or pursuant fo
any permit issued as a result of this applicaton agrees to, & shall, indemnify s
& 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 building
construction, and herebyfauthonze�representatives of this City to enter upon
the above-mentioned property for 'in spection.purptoses.
S gnature (Owner/Agent) 4 } ` Date+_� ;{'i
BUILDING PERMIT - PERMIT# -
� ti21:C..42
DATE ,,VALUATION LIT. � ,�y :2, TRACT •
dv-
JOB SITE,
ADDRESS 78-'815 � v U c�Ve�i'17.
APN
-.
OWNER
CONTRACTOR/DESIGNER/EN INEER
11480 E. 17TH Jt 01016
9522 ?: ALT)SOI ASA
�' 7 s `il ►` CA 92780
WC;IG'RNE VAu° vE Y CA 92356
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(760)248-6045 ;i
USE OF PERRMIT����yy-{�^�
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rNSPEC°'4'TOId, ,i�tII�1�It�§3I' 1 � '£ Sjai 4+•1+�J'3' iddC' ,IJ 3k;1
E91TUIAM COU 0r, CONSIMLIM10-N
1000m,
.PZ'RNJ1:.0 "3s SUMMARY
3'J.:M CHECK FED 18 $76.045
CaMSTRLICTIONt PV 1Q#-Ci410>d1��C�isO $t2`%iite
t'df"rU kl,Ntds`,C:.f LI IrEF, I. - POOL 101 "Ot' 0.4a.1 •-000 $24,00
ME;e:.'Pi,".',C..AL ikt:Z — tJaCOL 101-000-4,20-000 $45.01)
Pl:,llMBINO F.f&E -- BOOL 101.000-419-000 SAW
=w
soo-xaf�L CONVIRITC0110A AND PT AN C REM.
$289.05
" r 1ESS :t': F. PA11 ,E 3
$0,00
e ir,aa�ca+
V.�,.
NOV 2 2 2092;
- CITY OF LA QUINTA
BY
► � f.
D
-eRECE
3
PECTOR
k ? t
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Set Backs
steel
Electric Bond
POOLS - SPAS
S
Footings
Main Drain
�,.
Bond Beam
Approval to Cover
!T—
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
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
• ��
�7
Gas Piping
Gas Test
Appliances
Final
'7 0
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
4Utiltty Notice (Perm)
COMMENTS: