9904-019 (RPL)LICENSED CONTRACTOR DECLARATION
W I hereby affirm under penalty of perjury that 1 am licensed under provisions of
1- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
p License # Lic. Class Exp. Date
,ij 5741,277
cZ r~+ ate — Signature of Contractor`.�_w -•
V1 0
J U caO OWNER -BUILDER DECLARATION
HLU ^ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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
u7
N Date Signature of Owner
ON
a Q WORKER'S COMPENSATION DECLARATION
D Cc I hereby affirm under penalty of perjury one of the following declarations:
A H p () 1 have and will maintain a certificate of consent to self -insure for workers'
< tL u- compensation, as provided for by Section 3700 of the Labor Code, for the
JQ performance of the work for which this permit is issued.
Li Q (� ( )�� I have and will maintain workers' compensation insurance, as required by
j U Q Sebtion 3700 of the Labor Code, for the performance of the work for which this
L m 1 _ permit is issued. My workers' compensation insurance carrier & policy no. are:
win Z Carrier Policy No.
Q (This section need not be completed if the permit valuation is'for $100.00 or less).
J ( ) 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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code; I shall forthwith comply with. those provisions.
D,ate: d.�--;:r . Applicant _
�4
'Warning: Failure to secure Workers' Compensation coverage is nawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made:to the Directorof Building and Safety
for a permit subject to the conditions and restrictions .set forth on his
4 application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this, application becomes null and void if
work is not commenced within 180 days from date of issuance. of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that l have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
i Signature (Owner/Agent) `' G 1 Date_ cy
PERMIT #
BUILDING PERMIT
DATE VALUATION.i�e���.�Q) LOT TRACT
y ri
; . (.1.
JOB ADDRESS �8S 3DQD BT.�difflliiF. CD6�9Vi?
APN e —
OWNER
CONTRACTOR/DESIGNER/ENGINEER
;AL'A'I
S1'EV'F.. I", ACK,
45-"300 DEBBIE DRI'VE
7_101 1 CCiI. KI'I Y C U18 DR., SUi il4
LA QUINTA CA 911,153
fJALNI DESS ki' CA 92260
(W40,146-11032 032 (; UM t.044
USE OF PERMIT
!'{.>F.)[.:k4L)IUK SPA
4 5--, . ifI ii 01A. Y - ALA.ICM: i RT2IFURS MUST 13L iN PL&C% AT
fYlt17-kr1,A;S'1"iZ 1Nf;N1A:"l'IcyN.
Y�J' :�7JZIfl.s'll� STI,A AG.4.V{�1.�� L
PLAN QfI(c;K.fr:6:k.' 101- 9-4)-43!:-319 17 0')
r"f•�AJ`'t'f{ITf"I't(�NA►�'i? i(,i1-1111(!-�tljt-1'f!)tl 9t1$Il,d7(i
AT '*JLQ-J1WAL 1 m Prrpi, 11)1' 0010 =121.0fYJ 5.�1 �110
f. i<i:1k.:TR1CAL 17LL' -- Kj: ,) , 101.-(W0_1121-0003 kiS: is
i'l.ti�'_ISiNi_(.i'Fi1; -� 4'i?t.�l. 1U1-()1)()_41-t)li0 78b7.in)
$1. l IC"1'rAl, f: (JNS"I'R cri0N FANS 1 Vll..AN (_3-4F K
KoI iU3
LESS PRE -PAID F ES
$000
TOTAL if'r,1Rti0 Ff. fF EEN9 OU Ij; rNOW
$393.400
,
J
REC _P DATE
BY
DATE FINALED
INSPECTOR
a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION IDATE
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.
Gulls
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKYVALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric JA
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 Piaster
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)