9612-064 (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 3'6f, th,e Business and
Professionals Code, and my License is in full force and effect.
License # •Lic. Class ii If ;EXD. Date.
518742 'S�3
Ze F NA L Signature of Contractor_
/07
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 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
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:
Cartier 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 forwhich�thls permit is issued,
I shall not employ any person in any manner so as,
tobecomesubject to the
workers' compensation,laws of California, and 'agreeit at if I should become
subject to the w6f ers'`Compensation provisions of`Section, f3 00 of thelabor
Code, I sh II fo hwith comply with those provisions`
Date: - A Applicant
Warning: allure tosecure.W„orkers-C pen overa a is unlawful and
shall subject an employer to criminal penalties and civil fines ilp 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.
Ry2. Any permit issued as a result of this application becomes null and void if
,},71�work is not commenced with in'1.80 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;h eb'y'authorize-representatives of this City to ent r upon
the above meritioned,property for inspection purpose.
'
Signature
BUILDINGPERMIT PERMIT# °°NTR°`" -
DATE VALUATION LOT TRACT 470
41).0 0
JOB SITE
ADDRESS 47_525I U NIOrii fANA
APN
J
OWNER
CONTRACTOR/DESIGNERS ENGINEER
»AEJ.;. ;vtt���vttL.
M'(111111C IKK 1,10 X r'OZsJS'i'R%,1C:I'ff:)1J
47-525 VIA N9:ClWANA
68575 SIN FE1APH W
LeiQi1INTA, CA !x'2.25
C:t1'CHkiiNALCITY CA 92234
1-% C,:BIIN I1.(m
USE OF PERMIT.f,'t_tE.f�
ANlSPA
POOL AND &F %.lNLY
° raA_P% siXO i SPA S
.1, -owit off C
PIAN (31it{c"K FEE tf)1<(?tN)�43"f-Stt4 ��27.:1k
r;�� JAfR Y'lf �tF t f E R• i +'>'F; f f►j {){)f1 -d1 R Q(}{) !x''49 Y1
11IX1fb [*%'11 L 111111 •, 1'0t„+1, f?)f-000. 42.!•000 $11,00
I5f i:'c...l'13f't .tit.I 1�,_..,Pi.' ?L 101-000 -420 -OW �4 1)!_►
KI.l&WfNC VF;f, I*a�4 yt., lfJl-t>t}fJ-41''�•tf) $`w',:ti0
NUT -01 iTM, (.10N$fRUC"I'I0N .A:P3D�}k'I.,d1N C:.ttfE?gC'1,yi:.l
$67269
t
1?1:)U NOW
$672469
RECEIPT j
DATEB1
/ ' (
DATE FINALED
INSPECTOR
Date i E
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
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test '
Electric Final Dlf
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
f Al
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
a ttylity Notice (Perm)
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